Name: | DOB: | MRN: | PCP:

Request an Activation Code: Adult To Adult

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:

* I have legal guardianship rights or an Activated Durable Power of Attorney for Healthcare to access this Patient's record.
* I will comply with the terms and conditions on the MYchart web page and this document. I have the proper docuemntation authorizing me as a legal representative for this patient, thereby allowing me access to his/her protected health information through MYchart.
* When my legal authority to act on behalf of the patient has been inactived, revoked, terminated, or expired, I must immediately notify this institution in writing of the revocation, termination, or expiration.
* Even if my legal authority to act on behalf of the patient has not been inactivated, revoked, terminated, or expired, my access to this patient's MYchart protected health information will expire three years from the signature date of this document. I will then to complete this form again to obtain access for another two years.

 
Patient Information
 
Proxy Information
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.