Patient Portal Proxy Access Request and Authorization

Patient Information

Patient Name*

First Last

Patient Date of Birth*

Patient Social Security Number*

Patient Gender*

Patient Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Phone*

Patient Email*

Patient Agreement

This form is an Authorization that will permit the person named on the reverse of this form (your proxy) to have access to the information about you in your patient portal. Please read it carefully. All of your medical information that is available in your patient portal will be available to your proxy if you sign this Authorization. Patient portals include information related to mental health treatment, sexually transmitted diseases, HIV/AIDs, genetic testing, and incidental records related to alcohol and substance abuse.

If there is information that you do not want your proxy to see, then you should not sign this Authorization.

Health information to be accessed: All information contained in my patient portal medical record.

Purpose of portal access: To allow my patient portal proxy to view my medical information.

I authorize the release of my patient portal medical information to my proxy through proxy access to my patient portal account. This Authorization does not authorize the release of my medical information by other methods or other formats. I understand that once information has been disclosed, it may potentially be re-disclosed by my proxy and the disclosed information may not be protected by state or federal privacy laws. I understand that authorizing Presence Health/Amita Health and my physician to disclose my medical information to my proxy via the patient portal is voluntary. I understand that Presence Health/Amita Health and will not condition healthcare treatment or payment for treatment upon my signing this Authorization. Presence Health/Amita Health and my physician are not receiving any remuneration from any third parties because of this Authorization.

You may revoke this authorization at any time by submitting a written request to revoke proxy access to your physician’s office and/or your hospital’s Health Information Management Department.

For minors under 12, the authorization is valid until your 12 th birthday. For minors 12 and over, the authorization is valid until your 18th birthday unless you submit a written request to revoke proxy access to your physician’s office and/or your hospital’s Health Information Management Department.

I understand that a revocation is not effective for uses and disclosures of my medical information that have already been made or other actions that have been taken in reliance on this Authorization or as required by law. I understand that I am entitled to a copy of this Authorization and that I may review a copy of Amita Health’s and my physician’s Notice of Privacy Practices at any time by contacting Amita Health and my physician’s office or by accessing the following:

Amita Health Notice of Privacy Practices: https://www.amitahealth.org/privacy-policy/
Diamond Headache Clinic Notice of Privacy Practices: https://www.diamondheadache.com/privacy-policy

I acknowledge and agree that I will comply with all requirements listed on this document and the Terms and Conditions of Use available by accessing https://mychart.presencehealth.org/mychart/Authentication/Login?mode=stdfile&option=termsandconditions

Do you, the Patient agree?*

I agree.

Proxy Information

Proxy Name*

First Last

Proxy Date of Birth

Proxy Social Security Number*

Relationship to Patient*

Proxy Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Proxy Phone*

Proxy Email*

Proxy Access Request*

Check the best description of the preferred Proxy access

Adult Patient (Access to another adult’s patient portal information: This section also applies to emancipated minors who have provided proof of emancipation.)
Minor Patient (Access to a minor child’s patient portal information: Individuals requesting Proxy access must have parental or legal guardianship rights.)

Select One*

My Relationship to the Patient is:

Adult-Capable Adult Patient (The patient must sign this form to provide authorization for release of patient-portal information. Authorization for Proxy access is valid until revoked in writing by the patient.)
Legal Guardian
Power of Attorney for Health Care

My relationship to the minor is:*

Select One

Parent
Legal Guardian (Requires attachment of guardianship letters of office verifying the Proxy’s status as patient’s legal guardian.)

The minor patient is:*

Select One

Adult-Minor Patient / Age 0-11 (You will be granted full access to your child’s record until the patient reaches the age of 12. When the patient reaches the age of 12, parental or guardian access will automatically be turned off.)
Adult-Minor Patient / Age 12-17 (Parental or guardian access to the records of a patient age 12 to 17 is permitted only with the written consent of the child. Authorization for Proxy access given between the ages of 12 and 17 is valid until revoked by the patient in writing or until the patient turns 18.)

Proxy Agreement

By signing below, I acknowledge and agree that I:

Will use my own patient portal account to access the patient’s portal information.
Will comply with all usage requirements defined in the Terms and Conditions of Use available by accessing https://mychart.presencehealth.org/mychart/Authentication/Login?mode=stdfile&option=termsandconditions
Understand the patient (ages 12 and above) can revoke my access to his/her patient portal account at any time

Do you, the Proxy agree?*

I agree.

Patient portal proxy access request and authorizationn

Patient Information

Patient Agreement

Proxy Information

Proxy Agreement

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