Proxy Form - Avera Health Access To Records
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Access to a patient’s AveraChart Record
To request access to the AveraChart record of a patient whose medical care the proxy helps manage, please complete
this form. Completing this form will establish an AveraChart for the proxy and for the patient. Please note, the proxy will
access the patient’s records through the proxy’s access. A separate form will need to be completed for each patient and/
or proxy. Please allow approximately seven (7) business days for proxy access to be established. After proxy access is
established an e-mail will be sent to the address provided. Click on the link in the e-mail to gain access to AveraChart.
The link will expire at 10 days.
Patient Information
Complete this section with information about the patient whose AveraChart the proxy is requesting to access.
* Required Fields.
*Name (last, first, middle name):______________________________ *Date of Birth: ____________ *Gender: M / F
Last 4 digits of SSN: ___________________________ *Phone Number: _________________________________
Street Address: ____________________ City:______________________ State:______ Zip: __________________
Proxy Information
This section should be completed by the individual requesting access to a patient’s AveraChart.
* Required Fields.
*Name (last, first, middle name):______________________________ *Phone Number: _____________________
Street Address: ____________________ City:______________________ State:______ Zip: __________________
*E-mail: _____________________________________________________________________________________
If you are a patient at an AveraChart facility and would also like access to your own record, please provide us with:
*Date of Birth:___________________
*Gender:___________
Authority of Proxy
______ Patient is a minor under 12 years old and I am the patient’s parent. My rights to seek medical information on the
minor patient have not been limited by court order.
______ Patient is a minor under 12 years old and I am the patient’s guardian. See the attached paperwork which is still in
effect.
______ Patient is an incapacitated person and I am the patient’s guardian. See the attached paperwork which is still in
effect.
______ The patient, including patients at least 12 years old and older, has authorized my access to medical record
information. See Patient section below.
______ Other: ________________________________________________________________________________
_____________________________________________________________________________________
Proxy access for minors is limited to parents and legal guardians.
If proxy access is not authorized, you may request copies of the medical record by contacting Health Information
Management at the facility where care was provided.
AveraChart terms and agreement
•
I understand that AveraChart is intended as a secure online source of confidential medical information. If I share
my AveraChart ID and password with another person, that person may be able to view any health information to
which I have access through AveraChart.
•
I agree that it is my responsibility to select a confidential password, to maintain my password in a secure manner
and to change my password if I believe it may have been compromised in any way.
•
I understand that AveraChart contains selected, limited medical information from a patient’s medical record and
that AveraChart does not reflect the complete medical record.
•
I understand that my activities within AveraChart may be tracked by computer audit and that entries I make may
become part of the patient’s medical record.
•
I understand that access to AveraChart is provided as a convenience to its patients and that access to AveraChart
may be deactivated at any time for any reason. I understand that use of AveraChart is voluntary and I am not
required to use AveraChart or to authorize an AveraChart proxy.
Proxy Access Form
Form 8691-140 (English) (Rev. 6/16) (FO)
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