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06477000Parental/Guardian Proxy Access to a Teen’s MyChart Record (Ages 12-17)La Pine Community Health Center (LCHC) can provide limited access to a teen’s electronic health information in MyChart to the parents or legal guardians of adolescents age 12-17. The patient and parent/guardian must both sign this form to provide authorization for the release of medical information in MyChart. Please note that the patient’s chart will be accessed through the proxy’s MyChart record. Completing this form will establish a MyChart record for your assigned proxy. Proxies will have limited access to the teen’s personal health information including allergies, medical history, immunizations, etc.Proxies will be able to view messages in the Inbox tab but will not have access to view sent messages from the teen unless previously added by the teen in the initial message.Proxies will be able to send “New Medical Question” and “Customer Service Question” types from the proxy teen account.When a proxy sends a message, they will have the option to decide who can view the message (teen, proxy, or both) by unchecking the available boxes in the field. The system will allow both teen and proxy to view, by default, if not box is unchecked.Proxies will not have access to appointment messages (reminders, scheduled notices, cancellations, etc.)Form must be completed and returned to a La Pine Community Health Center employee.This section should be completed by the parent/guardian requesting access to their teenage child’s MyChart record.Parent/Guardian Last Name First Name M.I.DOB (mm/dd/yyyy)Email AddressPhone NumberMailing Address City State ZipPatient Last Name First Name M.I.DOB (mm/dd/yyyy)Email AddressPhone NumberMailing Address City State ZipMyChart Terms and AgreementProxy (Parent/Guardian): By signing below, I understand and agree to the following:I am entitled to access the patient’s protected health information as his/her parent or legally appointed guardian.My rights to access the patient’s protected health information have not been modified in any manner by court of law.The documents I have provided in support of my right to access the patient’s protected health information, if any, are true and correct copies and are the most recent documents related to this matter.Parent/Guardian Signature: __________________________________Date:________________________Teen (Patient): By signing below, I understand and agree to the following:I am authorizing LCHC to give proxy access to the parent/guardian listed above. I acknowledge that I have read and understand this authorization form. I agree to its terms and choose to designate the person named above as my MyChart Proxy, thereby allowing them access to my MyChart medical record.I understand that my proxy will have online access to my medical information that is currently available and that may become available as a result of future medical care. I understand that I may revoke this access at any time by providing a written request to LCHC.Teen Signature: ___________________________________________Date:________________________Patient MRN: Proxy Activation Date: Document sent to Records (employee initials):Employee Printed Name: Employee Signature: ................
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