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1. Your information: (Please print clearly) T New user T Request proxy user T Renew proxy user Your Name ________________________________________ ___________________ Medical Record # _____________ Address ________________________________________ ________________________________________ __________ Previous Names ____________________ Social Security # (optional) ___________ Birth Date ___________________ Home Phone _________________ Work Phone ___________________ E-mail _______________________________ Primary Doctor ________________________________________ _____ Primary Clinic _________________________ MyChart AccessMailed to PatientsAuthorization to Release Protected Health InformationI allow Fairview Health Services and its partners to release medical information through MyChart to: T Myself T My proxyPlease release the following details: All information as allowed through ask that you release this information for the following: T Personal use T Other: ______________I understand that: MyChart access includes all MyChart information from visits to all care providers using Fairview s shared electronic

2. Giving others access to your medical records (called proxy access) You may grant another person full access to your records. This might Ee a parent spouse adult child or