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MyChart - Adult Proxy Form

To request access to the MyChart record of an adult whose medical care you help manage, please complete this form. The patient must sign this form and provide authorization for release of medical information in MyChart on the “Adult Proxy Authorization Form.” Please note that the patient’s chart will be accessed through the proxy’s MyChart record. 

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MyChart - Teen Proxy Form

To sign up for access to your teen's MyChart record, please complete both pages of this Teen Proxy Form. Please note that your child’s chart will be accessed through your MyChart record.

MyChart

MyChart - Child Proxy Form

To request access to the MyChart record of an adult whose medical care you help manage, please complete this form. The patient must sign this form and provide authorization for release of medical information in MyChart on the “Adult Proxy Authorization Form.” Please note that the patient’s chart will be accessed through your the proxy’s MyChart record. 

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Notice of Privacy Practices

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Authorization to Release
Protected Health Information

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Authorization to Release
Medical Records

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Clinical Student Application

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