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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 My

1. Your information: (Please print clearly) T New user T Request proxy user T Renew proxy user Your Name _____ Medical Record # _____