MyChart Proxy Authorization

MyChart Proxy Authorization
Patient Information

(The person who's protected health information is being requested to be viewed through MyChart)
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Last 4 Digits of SSN*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Proxy Information

(The person authorized to access the patient’s protected health information through MyChart)
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Preferred Language*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Does your Proxy have an active Patient Portal account with SEH?*

No (If no, SEH staff will contact Proxy to create one.)Yes (If yes, SEH staff will complete the setup or contact the proxy for additional information as needed.)

Select Proxy Access Type*
Proxy Access Type Definition:
- Adult - Access to another adult's Patient Portal information. NOTE: this section applies to Emancipated Miniors; copy of proof of Emancipation must be attached to this form.
  - Capable Adult Patient - The patient must sign this form to provide authorization to release their medical information. Authorization for proxy access is valid until revoked by contacting your representative or via MyChart.
  - Guardian of Adult - Copy of legal documentation verifying your authority/guardianship or supporting documentation from your Employer Sponsor must be provided along with this Authorization release. NOTE: You must notify Southeast Health IMMEDIATELY in the event your authority/guardianship status changes for this Patient.
    
    Legal Guardian, court ordered
    
    Power of Attorney for Healthcare or Power Other
- Minor - Access to minor's Patient Portal information.
  - Parent - Biological, Adoptive, Step-Parent
  - Permanent Legal Guardian of the Patient - Copy of Court Order Appointing Guardian and Letters of Guardianship verifying the Proxy’s status as permanent legal Guardian of the Minor/Child must be attached to this form.
Age Defintion:
- 0-13 years old - You will be authorized to full access to your minor’s health care information with SEH until the minor turns 14 years old.
  1. Your minor’s record will be accessible through your MyChart access point.
  2. When the patient turns 14 years old they can choose whether parent/guardian can have access to their MyChart. If continued access is desired by both Patient and Proxy, a new MyChart Proxy Authorization form can be completed.
- 14-18 years old - Patients of 14-18 years old can choose to permit whether their parent(s) or guardian(s) are authorized to access portions of their health care information specially protected under state laws; this includes reproductive, STD, mental health and substance abuse information.
  1. When the Patient becomes 19 years old, parent/guardian access to their MyChart will be disconnected. If continued access is desired, a new Proxy Authorization form can be completed after they turn 19 years old.

To be completed by the PATIENT who is authorizing access to their health care information at Southeast Health

(Does not apply to Legal Guardian, Power of Attorney, or 0-13 years old)
AUTHORIZATION FOR ACCESS
to my personal MEDICAL RECORD/PATIENT PORTAL
1. By signing this proxy request, I understand that I am giving my permission for Southeast Health to disclose my protected health information (PHI) through the MyChart record to my proxy.
2. I am requesting that my proxy have access to my PHI that is available in my Southeast Health MyChart record.
3. I authorize Southeast Health to release the health information contained in my MyChart record to my MyChart proxy.
4. I understand that the medical information in MyChart is obtained by my electronic medical record and may include information from Southeast Health Medical Center and all Southeast Health clinics.
5. I authorize release of any information contained in my MyChart medical record held by Southeast Health to my designated proxy. I authorize release of this information only through my MyChart record.
6. This form does not authorize release of my medical record to my designated proxy by other methods or in other forms.
7. I understand that once information has been disclosed, it potentially may be re-disclosed by the proxy and the information may not be covered by federal privacy protections.
8. Participation in MyChart and designating a MyChart proxy is completely voluntary.
9. I understand that I am not required to designate a proxy and I am not required to provide this authorization. I also understand that Southeast Health does not condition any of my health care treatment, payment, or other services on whether I provide this authorization. However, I also understand that if I do not provide authorization, Southeast Health is not permitted to provide access to my MyChart record to my designated proxy.
10. I understand that the age of majority in the state of Alabama is 19 and my proxy’s access to my MyChart record will be available until I reach the age of 19, unless otherwise revoked.
11. I may revoke this authorization at any time by contacting my Southeast Health physician’s office, the Southeast Health Medical Records Office, or a Southeast Health registration desk, or via MyChart. I understand that if I revoke this authorization, my designated proxy’s access to my MyChart record will be ended. I understand my revocation will not affect any disclosures that were made prior to processing the revocation request. I understand that termination of proxy access is not immediate. Southeast Health will use its best efforts to terminate access within ten (10) business days of receiving notification. Additionally, I understand that I may mail the revocation in writing to Southeast Health, Medical Records Department, 1108 Ross Clark Circle, Dothan, AL 36301.
12. I acknowledge that I have read and understand the MyChart Proxy Authorization form. I agree to its terms and choose to designate the person named on this form as my MyChart proxy, thereby allowing them access to my MyChart medical record.
Please select access type:*

Complete AccessRestricted Access
Adult or Minor Patient 14-18 years old
By signing below, I acknowledge and agree to comply with the SEH MyChart Terms and Conditions, located here, as they may be revised from time to time, without further notice:
Adult or Minor Patient Name:*

First NameLast Name
Adult or Minor Patient Signature*

Clear
Date*

MonthDayYear
Date

To be completed by the PROXY

Copy of any legal documents must be attached to this form when submitted for processing. Incomplete forms will not be accepted.
By signing below, Power of Attorney acknowledge and agrees:
- I have legal rights to access the patient’s MyChart Record.
- There are no court orders or restraining orders in effect limiting my access to this patient's medical records and/or information.
- Communications on behalf of the patient through MyChart must be sent from the patient’s record and be received in the patient’s record. MyChart e-mail alerts will be sent to the e-mail address entered under the Power of Attorney's (“Proxy”) Information.
By signing below, legal guardian acknowledge and agrees:
- I have legal guardianship rights to access the patient’s MyChart Record.
- There are no court orders or restraining orders in effect limiting my access to this patient's medical records and/or information.
- Communications on behalf of the patient through MyChart must be sent from the patient’s record and be received in the patient’s record. MyChart e-mail alerts will be sent to the e-mail address entered under the Legal Guardian (“Proxy”) Information.
By signing below, parent or legal guardian acknowledge and agrees:
- I have parental rights or legal guardianship rights to access the Minor’s MyChart Record.
- I have not been denied periods of physical placement with the Minor and there are no court orders or restraining orders in effect limiting my access to this Minor's medical records and/or information.
- Communications on behalf of the Minor through MyChart must be sent from the Minor’s record and be received in the Minor’s record. MyChart e-mail alerts will be sent to the e-mail address entered under the Parent/Legal Guardian (“Proxy”) Information.
- For a Minor age zero to 13 years, I will be granted full access to the Minor’s MyChart record. On the Minor’s 14th birthday, a new MyChart Proxy Authorization form must be completed.
LEGAL GUARDIANS:

All documents, if any, I have provided in support of my request to access the patient’s protected health information, are true and correct copies and are the most recent documents related to this matter. When my legal authority to act on behalf of the patient has been inactivated, revoked, terminated, or expired, I must immediately notify SEH in writing of the change in authority & the date it became effective, and mail it to: Southeast Health, Medical Records Department, 1108 Ross Clark Circle, Dothan, AL 36301.
Proxy:
By signing below, I acknowledge, agree & understand:
1. I will comply with the SEH MyChart Terms and Conditions, located here, as they may be revised from time to time, without further notice.
2. The patient can revoke my access to his/her Patient Portal account at any time unless the patient is a minor aged zero to 13.
Proxy Name:*

First NameLast Name
Proxy Signature*

Clear
Date*

MonthDayYear
Date
File Upload

Cancelof
Should be Empty:

MyChart Proxy Authorization

Patient Information

Proxy Information

To be completed by the PATIENT who is authorizing access to their health care information at Southeast Health

To be completed by the PROXY