ACCESS TO A CHILD, TEEN, OR ADULT
MYUCSDCHART RECORD (PROXY ACCESS)
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 specied 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 veried. 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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