Authorization for Proxy Access

I understand that my proxy will have the same access and privileges that I have for the Patient Portal. I understand that this allows my proxy online access to my personal health information. My proxy will be able to view portions of my record that I am able to view. I also understand that additional information may be made available to my proxy through the patient portal as Memorial Health System continues to implement this product.

By signing this authorization, I am requesting Memorial Health System to give access to my proxy to utilize the patient portal. I understand that Memorial Health System will require my proxy to sign an acknowledgment and agree to Memorial Health System's policies and procedures for use of the patient portal. I understand that I am giving the proxy full access to all of my visits within myMemorialChart.

This authorization is valid until revoked by me. I understand that a written request is necessary to revoke or cancel this authorization. However, I understand that my revocation will not be effective as to uses and/or disclosures already made in reliance upon this authorization. I realize that the information used and/or disclosed pursuant to this authorization may be subject to re-disclosure and no longer protected by federal privacy laws.

Patient Acknowledgment

Proxy Acknowledgment & Information

I authorize the following individual to participate in Memorial Health System's Patient Portal as my proxy.

*Proxy is the person who has access to the patient's myMemorialChart.