Adult proxy form
Access to another adult’s interactive health record
To request access to the interactive health record of an adult whose health care you help manage, please complete this form. The patient
must sign this form and provide authorization for release of health information. Please note that the patient’s chart will be accessed
through your (the proxy’s) Allina Health account. Completing this form will establish an Allina Health account for you and access to the
adult’s interactive health record.
Return all forms to: Account Services or fax 612-262-1424
Mail Route 10607, 2925 Chicago Avenue, Minneapolis, MN 55407
Your information: (all sections required – please print clearly)
This section should be completed by the individual requesting access to another adult’s record.
Name (last, first, middle initial)
Last 4 digits SSN: Date of birth:
Street address: City: State: Zip:
Email address: Phone number:
Check the box next to the organizationthat provides yourprimary care (select one):
Allina Health Cuyuna Regional Medical Center FirstLight Health System
Glencoe Regional Health Services Hutchinson Health River’s Edge Hospital & Clinic
Riverwood Healthcare Center St. Croix Regional Medical Center United Family Medicine
The Urgency Room Western Wisconsin Health/Baldwin Area Medical Center
Patient’s information: (all sections required – please print clearly)
Complete this section with information about the adult whose interactive health record you are requesting to access.
Name (last, first, middle initial)
Last 4 digits SSN: Date of birth:
Street address: City: State: Zip:
Email address: Phone number:
Check the box next to the organizationthat provides yourprimary care (select one):
Allina Health Cuyuna Regional Medical Center FirstLight Health System
Glencoe Regional Health Services Hutchinson Health River’s Edge Hospital & Clinic
Riverwood Healthcare Center St. Croix Regional Medical Center United Family Medicine
The Urgency Room Western Wisconsin Health/Baldwin Area Medical Center
Allina Health account terms and agreement
• I understand that my Allina Health account is intended as a secure online source of confidential health information.
If I share my username and password with another person, that person may be able to view my or my child’s health
information, and health information of someone who has authorized me as a proxy.
• I agree that it is my responsibility to select a confidential password, to maintain my password in a secure manner, and to
change my password if I believe confidentiality may have been compromised in any way.
• I understand that it is my responsibility to ensure that my email address is current at all times, and that if my email address
is not current I will not receive important messages from Allina Health.
• I understand that the interactive health record contains select, limited medical information from a patient’s health record
and that it does not reflect the complete contents of the health record. I also understand that a paper copy of a patient’s
health record may be requested.
• I understand that my activities within my Allina Health account may be tracked electronically and that entries I make may
become part of the health record.
• I understand that access to the Allina Health account is provided as a convenience to patients and that Allina Health has
the right to end access at any time, for any reason.
• I understand that my use of my Allina Health account is voluntary and I am not required to use my account or to authorize
a proxy.
Your (proxy) signature (required) Relationship to patient Date (required)
I acknowledge that I have read and understand this adult proxy form.I agree to its terms and choose to designate the person
named above as my proxy, thereby allowing them access to my interactive health record.
Signature of patient (or authorized person) (required) Relationship to patient Date (required)
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
