Proxy for Minor Patient 0-12 Years of Age Express Waiver and Consent Instructions
The caregiver feature of MyHealthOne permits patients to grant access to their own MyHealthOne account so that others can view their health information. Caregivers should be trusted individuals and will be legally designated to access the patient’s health information.
To request caregiver permissions for a family member or loved one through MyHealthOne, or, permit someone else to have caregiver permissions for your MyHealthOne account, take the attached form to the hospital that the patient most recently visited. You will be required to complete and sign the form in the presence of a hospital representative at the patient registration, health information management, or medical records office.
If the patient is unable to sign the Waiver and Consent form, the patient’s Power of Attorney may sign on behalf of the patient. The Power of Attorney must present documentation and state-issued photo identification. If the patient is unable to sign the Waiver and Consent form but no Power of Attorney exists for the patient, then the caregiver or proxy enrollment cannot occur.
For patients aged 0-12
Please take the Proxy for Minor Patient 0-12 Years of Age Express Waiver and Consent to the hospital the minor patient most recently visited. A parent or legal guardian must present photo identification. Although anyone can be the caregiver or proxy, the Proxy for Minor Patient 0-12 Years of Age Express Waiver and Consent must be signed by the parent or legal guardian at the hospital’s registration desk.
For patients aged 13-17
Select a trusted individual as your caregiver. Please take the Proxy for Minor Patient 13-17 Years of Age Express Waiver and Consent to the hospital you most recently visited. A parent or legal guardian and the minor patient must both sign the Proxy for Minor Patient 13-17 Years of Age Express Waiver and Consent and present photo identification at the hospital’s registration desk.
For adult patients
Please take the Proxy for Adult Patient Express Waiver and Consent to the hospital you most recently visited. You will need to present photo identification at the hospital and be ready to provide information about your caregiver or proxy.
For the caregiver
All caregivers must be at least 18 years old, have an active email address, and present state-issued photo identification to the patient’s most recent hospital.
When the hospital has processed the form, please call the MyHealthOne support team at 1-855-422-6625 to complete the caregiver enrollment process.
For the hospital
As a hospital employee, if you have questions about this form, please call the MyHealthOne hospital Portal Support team. This form is also available on Atlas Connect.
Proxy for Minor Patient 0-12 Years of Age Express Waiver and Consent
I, the Parent or Legal Guardian, of the minor patient, request to be granted proxy access to my minor patient’s health and other information. I will comply with the terms and conditions of the privacy practices of Chippenham Hospital. I am representing and warranting that I am the Parent or Legal Guardian of the minor patient with the ability to enter into agreements relating to the consent to access and waiver of rights involving the minor’s medical data. I understand when the minor patient becomes 13 years old, my access and any access I have granted to my child or a delegate will be automatically terminated. Access to the account of children ages 13 through 17 years of age requires a new application process and the agreement of the child. I further understand and acknowledge that (a) Chippenham Hospital can rely on this waiver and consent until revoked by me in writing; (b) by providing this waiver and consent the named individual has the same rights to access my information as I do; and (c) that I waive all rights and remedies relating to the named individual’s use or misuse of my information that Chippenham Hospital provides the named individual pursuant to this Express Waiver and Consent. Please note that if this waiver and consent is revoked, such revocation will not affect any action taken in reliance on this waiver and consent prior to such revocation. If I want to revoke this Proxy Express Waiver and consent, I must call Patient Portal Support at 1-855-422-6625.
|Patient Name (Print):||Patient Medical Record Number:|
|Patient Account Number:||Patient/Authorized Patient Representative Signature:|
|Date of Consent:|
|Proxy Name (Print):||Proxy Email Address:|