MyChart - Request Proxy Access

To sign up for MyChart proxy access for another person whom you are designated as the Power of Attorney or Durable Power of Attorney, you need to complete this form. You must also have your own MyChart account established for access.

POA/DPOA Information

If the Proxy sees providers at the Organizations, the Proxy needs to also complete the Enrollment Form if not already completed.

First Name

Middle Initial

Last Name

Date of Birth

Address

City

State

Zip

Phone

Primary Provider

Proxy Access Request: POA/DPOA

POA/DPOA document verifying the Proxy’s status as legal representative must already be on file in the patient's chart or must be emailed to sm_mychartproxyforms@confluencehealth.org before proxy can be granted.

To request access to the MyChart record please provide their information below.

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 representative 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 Representative (“Proxy”) Information.

Proxy Signature (type full name)

Relationship to Patient

Date

Patient Information

Please provide the following information on your patient: (NOTE: If you have more than one patient for whom you would like MyChart access, please complete additional forms.)

First Name

Middle Initial

Last Name

Date of Birth

Last four digits of SSN

Primary Provider

MYCHART PROXY ACCESS FORM: POA/DPOA