Guardian Power Of Attorney Access (Page 2 of 3) in pdf

Medical Record No.

(5230)

Patient Name

Birthdate

Physician

Please align patient label to the right

Proxy Form (Guardian Power of Attorney 12 and Over)

Guardian/Power of Attorney Access to the Online MyChart Record of a Patient

Age 12 or Older - Authorization Form

Please enter Patient’s information below:

Patient’s Name: ____________________________________ Date of Birth: ______________________________

Address: _________________________________________ Gender: _________ Male _________ Female

_________________________________________

--------------------------------------------------------------------------------------------------------------------------------------------------

To be notified when new messages about patient’s care are sent to MyChart, please list an email address:

_____________________________________________________________________________________

Please enter Legal Guardian/POA information below:

Parent Name: ______________________________________ Date of Birth: ______________________________

Address: _____________________________________________________________________________________

Phone number on file: _________________________________________________

Please check the authorizing party’s relationship to the patient:

Parent of a disabled patient**

Legal Guardian of a disabled adult patient**

Durable Power of Attorney for Healthcare for a disabled adult

Durable Power of Attorney for Healthcare

Birth certificate

Other ______________________________________________

** This request MUST be accompanied by a copy of the legal paperwork verifying the authority of the patient’s personal

representative (i.e. birth certificate, court appointed guardian, durable power of attorney for health care)

Do you (parent/legal guardian/POA) have an active MyChart account? _____Yes _____ No _____

I have read and understand the requirements and procedures for accessing a patient’s medical information online

as provided on page one of this document titled, Guardian/POA Access to the Online Medical Record of a Patient

Age 12 or Older. I certify that I am the legal guardian or legal representative of the patient listed above and that

all information I have provided is correct. I hereby request access to the patient’s online record.

_______________

_______________________________________________________

Parent/Legal Guardian/POA Signature

Date

Form 5230 Revised 10/16 HIM Approved 5/11

Page 2 of 3

Guardian Power Of Attorney Access Page 2