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SummaryMyChart (electronic health record patient portal) proxy access adds a child or dependent to the parent/guardian’s MyChart account which will give them access to the patient’s medical records. With proxy access, a parent/guardian can perform all of the same tasks for the child/dependent as they can with a regular MyChart account. Proxy access can also be used for people having Power of Attorney or Legal Guardianship of a patient, regardless of the age.Age DisclaimerMyChart proxy access allows a parent/guardian access to the patient’s MyChart account. This access is available from birth until 12 years old. Proxy access will automatically end on the patient’s 12th birthday. This is to protect the rights of the child during their teenage years. The patient will be eligible to sign up for MyChart on their 12th birthday. ResponsibilityBy signing below you are declaring that you are the patient’s parent or legal guardian. As a proxy for the patient you may not give your MyChart access to a third party or person for any reason. Proxy access is intended for the undersigned only. If for any reason you are no longer the legal guardian of the patient you MUST notify La Pine Community Health Center within 10 days of the change so that proxy access to the patient’s chart may be removed. AgreementI, the undersigned, agree that I will protect the patient health information (PHI) entrusted to me as a proxy for the patient. I understand that the laws and regulations associated with the HIPAA and Omnibus rulings apply to me as a proxy for the patient. I further accept the responsibility and liability for this access. I understand that if I breach this responsibility in any way, my proxy access will be removed and I may be held legally liable. I understand and agree that my proxy access will be automatically terminated when the patient turns 12 years old. This agreement shall be in effect as long as my proxy access is active and all activities that are performed using MyChart proxy access fall under this agreement. Patient for which proxy access is granted_______________________________________ DOB____________Parent/Guardian to whom proxy access is granted_____________________________________ DOB_____________Parent/Guardian Signature___________________________________________ Date______________ ................
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