MyChart - Request Proxy Access

To sign up for MyChart access for an adult whom you are appointed as a legal guardianship/conservator, the legal guardian/adult proxy needs to complete this form. The legal guardian/adult proxy must also have his/her own MyChart account established for access.

Legal Guardian/Adult Proxy information

First Name

Middle Initial

Last Name

Date of Birth

Address

City

State

Zip

Phone

Primary Provider

Proxy Access Request

Legal documentation that stipulates legal guardianship/ conservator of the adult patient by the adult proxy must already be on file in the patient's chart or must be emailed to sm_mychartproxyforms@confluencehealth.org before proxy can be granted.

These limitations do not affect any legal right you have to access the patient’s record by other means. To request a paper copy of the patient’s record, please contact the Health Information Management Department.

By signing below, I acknowledge and agree that:
• I will be using my own MyChart account at the Organization to access this patient’s MyChart account.
• I will keep my password confidential and not share this information with anyone.
• I must be the legal guardian/conservator for this patient.
• Communications on behalf of the patient through MyChart must be sent from the patient’s record and responses will be received in the patient’s record. MyChart e-mail alerts will be sent to the e-mail address entered under Legal Guardian (“Proxy”) Information.

Adult Patient / Grantor Signature (type full name)

Relationship to Patient

Date

Patient Information

Please provide the following information on the adult patient: (NOTE: If more than one adult proxy access is required, please complete an additional form(s))