Fillable Proxy for Minor Patient 0-12 Years of Age

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Proxy for Minor Patient 0-12 Years of Age

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*MTPORT*
*MTPORT*
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 r
equest 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.
Fo
r 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.
Fo
r 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.
Fo
r 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.
Wh
en the hospital has processed the form, please call the MyHealthONE support team at 1-855-422-6625 to
complete the caregiver enrollment process.
Fo
r 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.
www.myhealthone.com
*MTPORT*
*MTPORT*
Prox
y 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 the HCA Healthcare facility). 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) the HCA Healthcare facility 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 the HCA Healthcare facility 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 Information
Patient Name (Print):
Patient Medical Record Number:
Patient Account Number:
Parent/Legal Guardian Signature:
Date of Consent:
Proxy Information
Proxy Name (Print):
Proxy Email Address:
www.myhealthone.com
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Proxy for Minor Patient 0-12 Years of Age

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Completed 27 November 2021

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