Transcription of r - fvfiles.com
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r - fvfiles.com
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 medical record.
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
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