Fillable Form and present to your clinic registration staff. (University of California, San Diego)

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Form and present to your clinic registration staff. (University of California, San Diego)

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ACCESS TO A CHILD, TEEN, OR ADULT
MYUCSDCHART RECORD (PROXY ACCESS)
D3988 (1-17) Page 1 of 3
To request access to another’s MyUCSDChart patient web portal record, please complete all pages of this Proxy Access Request
Form and present to your clinic registration staff. Access to the child, teen, or adult’s MyUCSDChart will be through your
MyUCSDChart account. The MyUCSDChart patient web portal is at https://myucsdchart.ucsd.edu.
Please select from the following Proxy Access options and follow the instructions:
Child Proxy – If the patient is a minor between the ages of 0 – 11, you will be granted full access to the minor
patient’s MyUCSDChart record until the child reaches age 12. Complete sections 1, 2 and 3 of this form.
Teen Proxy – If the patient is a minor between the ages of 12 – 17, access is limited to parental access to ensure
privacy for our patients in accordance with the California Condentiality of Medical Information Act (CMIA). Proxy access
to emancipated minor’s record follows Adult Proxy procedures. NOTE: The limitations in place for MyUCSDChart Proxy
Access do not affect any legal right you have to access the patient’s records by other means. To request a paper copy of
the patient’s chart, contact Health Information Management at 619-543-6704. Complete sections 1, 2 and 3 of this form.
Adult Proxy and Emancipated Minor Proxy – If the patient is an adult, 18 or older, consent from the
patient (or authorized legal guardian) is required for access to the patient’s MyUCSDChart record. Complete sections
1 and 4 of this form.
SECTION 1
Proxy Information: (All items required. Please print clearly.)
Name (last, rst, middle initial)
___________________________________________________________________
Social Security Number (last 4 digits): _________________ Date of Birth: __________________________________
Street Address: _________________________________________________ City: ________________________
State: ___________ Zip Code: ____________________ Phone Number: __________________________________
Email Address: ______________________________________________________________________________
Relationship to Patient: ________________________________________________________________________
SECTION 2
Please provide the following information for each child. All elds are required. If you have more than four children for whom
you would like proxy access, please print another form.
Child's Name (Last, First, Middle Initial)
Socal Security Number
(SSN) Last 4 digits
Date of Birth
A
B
C
D
Patient Identication
Clinic Use Only: Completed forms should be scanned into the patient's medical record and proxy access established
once identity has been veried. See http://tinyurl.com/h3uahtt for further instructions. Disregard scanning Page 3 if blank.
*D3988*
ACCESS TO A CHILD, TEEN, OR ADULT
MYUCSDCHART RECORD (PROXY ACCESS)
Patient Identication
USER ACKNOWLEDGEMENT OF TERMS & CONDITIONS FOR USE OF MYUCSDCHART
You are requesting access to UC San Diego Health (UCSDH) MyUCSDChart, which contains the online health information for
you or another person. By signing below, you represent that you have the legal right to access the information contained in
the patient’s medical record.
1. If you are a parent or other legally authorized representative of the patient, you certify and represent that no court has
terminated your parental or legal rights with respect to the patient or otherwise restricted your access to the patient’s
information.
2. By using MyUCSDChart, you afrm your acceptance of MyUCSDChart’s Terms and Conditions and agree to comply with
them now and throughout the period of your use of MyUCSDChart. If you do not agree to the Terms and Conditions,
do not proceed to use MyUCSDChart.
3. Parents or guardians of children age 0 –11 must complete the enrollment process in person. Birth or adoptive parents
must present photo identication and sign this form acknowledging that they have a right to the child’s health care
information. If you are not the birth or adoptive parent of the child, you must present legal paperwork (such as a court
order or medical power of attorney) proving you are the legally recognized caregiver for the child.
4. You agree that it is your responsibility to select a condential password, to maintain your password in a secure manner,
and to change your password if you believe it may have been compromised in any way.
5. You understand that MyUCSDChart contains selected, limited medical information from a patient’s medical record and
that MyUCSDChart does not reect the complete contents of the medical record. You also understand that a paper
copy of a patient’s medical record may be requested from the UC San Diego Health Health Information Management
Department.
6. You understand that your activities within MyUCSDChart may be tracked by computer audit and that entries you make
become part of the patient’s legal medical record.
7. You understand that access to MyUCSDChart is provided by UCSDH as a convenience to its patients and that UC San
Diego Health has the right to deactivate access to MyUCSDChart at any time for any reason. You understand that use of
MyUCSDChart is voluntary and you are not required to use MyUCSDChart or to authorize a MyUCSDChart proxy. UCSDH
reserves the right to revoke online access to MyUCSDChart at any time.
8. By signing below, you acknowledge that you have read and understand this MyUCSDChart Proxy form and you agree to
its terms.
SECTION 3
Proxy signature (Parent/Guardian): ______________________________________________ Date: ____________ Time: _________ AM / PM
Printed Name of Proxy (Parent/Guardian): _________________________________________ Relationship to Patient:_____________________
If Interpreted: __________________________________ __________________________ Date: _____________ Time: AM / PM
Telephone Video Interpreter OR ID# Language
Clinic Use Only: Completed forms should be scanned into the patient's medical record and proxy access established
once identity has been veried. See http://tinyurl.com/h3uahtt for further instructions. Disregard scanning Page 3 if blank.
D3988 (1-17) Page 2 of 3
ACCESS TO A CHILD, TEEN, OR ADULT
MYUCSDCHART RECORD (PROXY ACCESS)
SECTION 4
Patient Identication
Proxy Information: (All items required. Please print clearly.)
Name (last, rst, middle initial)
___________________________________________________________________
Social Security Number (last 4 digits): _________________ Date of Birth: __________________________________
Street Address: _________________________________________________ City: ________________________
State: ___________ Zip Code: ____________________ Phone Number: __________________________________
Email Address: ______________________________________________________________________________
I am requesting that (insert name of proxy) ___________________________________________ receive access to
my health information that is available in MyUCSDChart. This person is my designated MyUCSDChart proxy. I authorize
MyUCSDChart to release the health information contained in my MyUCSDChart record to my MyUCSDChart designated proxy.
I understand that the medical information in MyUCSDChart is obtained from my electronic health record. I authorize release
of this information only through my MyUCSDChart record. This form does not authorize release of my health record to my
designated proxy by other methods or in other formats. I understand that once information has been disclosed, it potentially
may be re-disclosed by the proxy and the disclosed information may not be covered by the same privacy protections.
Participating in MyUCSDChart and designating a MyUCSDChart proxy are completely voluntary. I understand that I am
not required to designate a MyUCSDChart proxy and I am not required to provide this authorization. I also understand that
MyUCSDChart does not condition any of my health care treatment, payment or other services on whether I provide this
authorization. However, I also understand that if I do not provide authorization, MyUCSDChart is not permitted to provide my
designated proxy access to my MyUCSDChart record.
This authorization will automatically expire ve years from the date of my signature. I also may cancel this authorization at
any time online within MyUCSDChart or by providing a written request for cancellation to my primary clinic. I understand
that if I cancel this authorization, my designated proxy’s access to my MyUCSDChart record will be ended. I also understand
my cancellation will not affect any disclosures that were made prior to processing the revocation before my cancellation
request is processed.
Patient or Authorized Signature: ________________________________________________ Date: ____________ Time: _________ AM / PM
If Authorized Signature,
Printed Name of Patient or Authorized Signature: ___________________________________ Relationship to Patient: ____________________
If Interpreted: __________________________________ __________________________ Date: _____________ Time: __________ AM / PM
Telephone Video Interpreter OR ID# Language
If person other than the patient signs, indicate authority to sign for patient (e.g., guardian) and attach documentation:
__________________________________________________________________________________________________
NOTE: Authorization expires ve years from the date of signature (above) unless child proxy reaches age 12 or upon
implementing an authorized request to revoke proxy access. This release of medical information form must be
submitted every ve years to renew proxy access. You also may deactivate the access of the adult proxy specied above
at any time through MyUCSDChart or by providing a written request to your primary clinic.
Clinic Use Only: Completed forms should be scanned into the patient's medical record and proxy access established
once identity has been veried. See http://tinyurl.com/h3uahtt for further instructions. Disregard scanning Page 3 if blank.
This section is an authorization that will permit UC San Diego Health to release your health
information to your designated adult proxy. Please read it carefully. This form should be completed
by the patient who is authorizing another adult to access the health information in his or her MyUCSDChart record.
D3988 (1-17) Page 3 of 3
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Completed 25 May 2021

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