MYchart -

Completing this form allows someone else ("Proxy") to be able to access portions of the Patient's protected health information maintained by Children's Healthcare of Atlanta, Inc. and/or any of their electronic medical record affiliates (the "Organizations") through MYchart. The Patient (when applicable) and Proxy must agree and comply with the terms and conditions on the MYchart web page, and this document.

Proxy:
I acknowledge and agree that:
* The Patient can revoke my access to his/her MYchart account at any time.
* I will comply with the terms and conditions on the MYchart web page and this document.

Patient:
I acknowledge and agree that:
* I have completed the MYchart Authorization for User or Disclosure of Electronic Protected Health Information.
* I will comply with the terms and conditions on the MYchart web page and this document. I choose to designate the person named above as a proxy to my MYchart account, thereby allowing him/her to access my MYchart protected health information.
* I understand that if I no longer want the Proxy to have access to my MYchart account, I must contact the Medical Records Department.

Patient Information

Name:

Street Address:

City:

State:

Zip:

Date of Birth (mm/dd/yyyy):

Phone Number (xxx)xxx-xxxx:

Patient: By typing my name in the space labeled "Signature" below (which shall constitute my signature), I hereby certify that the information furnished above is true and complete. I acknowledge that the name indicated above is my current full legal name and I am authorized to sign this form.

Patient Signature:

Date Signed:

Proxy Information

E-Mail Address:

Name:

Street Address:

City:

State:

Zip:

Date of Birth (mm/dd/yyyy):

Phone Number (xxx)xxx-xxxx:

Proxy: By typing my name in the space labeled "Signature" below (which shall constitute my signature), I hereby certify that the information furnished above is true and complete. I acknowledge that the name indicated above is my current full legal name and I am authorized to sign this form.

Proxy Signature:

Relationship to Patient:

Date Signed:

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