Patient Portal Proxy Consent

Authentication Key
Form Type
Patient Portal Proxy Access

Patient Portal Proxy Access Request and Authorization Form for review by Mountain Area Health Education Center, Inc. (MAHEC)
All Information is required to process your proxy authorization.
Patient Information
Legal Patient Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

City State

Zip Code
Proxy Information

Person to whom you authorize MAHEC to release the Patient Portal record
Legal Proxy Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

City State

Zip Code
Phone Number*
Email address*
example@example.com
Please check one of the boxes below that best describes the proxy access requested. (Please note that for all types of proxy access, the patient's chart will be accessed through the proxy's FollowMyHealth Patient Portal account.)*

Adult PatientMinor Patient
Adult Patient:
- Access to another adult's patient portal record.
- Note: This section also applies to emancipated Minors. Emancipated Minors must provide proof of emancipation.
Minor Patient:
- Access to your minor child's patient portal record
- Individuals requesting access must have parental rights or be the court appointed legal guardian for the minor patient.
Adult Patient

Access to another adult patient portal record. Please note that this section also applies to emancipated minors. Emancipated minors must provide proof of emancipation
Select One:*

Adult for capable adult patientLegal guardian of adult patient
Adult for capable adult patient:
- The patient should sign this form to provide authorization for release of his/her medical information.
- Authorization for proxy access is valid until revoked by patient
Legal Guardian of Adult Patient
- Adults who have a surrogate relationship with another adult through a legal arrangement
Select the option below that best describes the guardianship:*

Legal Guardianship (court order)Power of Attorney for Health CareOther
- If you are the legal guardian or you have power of attorney for healthcare for this patient, this request must be accompanied by a copy of the legal paperwork verifying your authority to have access to the patient's medical information.
- You must notify MAHEC Immediately in case of any change of authority.
Adult patient legal paperwork upload*

Cancelof
Minor Patient

Access to your minor child's patient portal record. Individuals requesting access must have parental rights or be the court appointed legal guardian for the minor patient.
My relationship to the child is:*

ParentLegal guardian of the patient (must attach a copy of the court appointing you as the minor patient's legal guardian.)
Must attach a copy of the court order appointing you as the minor patient's legal guardian*

Cancelof
Patient Authorization:
- By signing this proxy request, I understand that I am giving my permission for MAHEC to disclose my protected health information (PHI) through the Patient Portal to my proxy which may include sensitive information such as treatment for pregnancy, drug/alcohol abuse, mental health, HIV status, genetic testing and labs, if applicable.
- This proxy request is effective until my Patient Portal account is inactivated or I revoke proxy access.
- This proxy request includes records that were created or existing on or before the date this form was signed, as well as records that are created after the date this form is signed.
- I understand that I have a right to revoke this authorization at any time. If I want to revoke this authorization, I must do so in writing. I understand that such a revocation will not have any effect on any information already released to my proxy.
- I understand that the information disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by federal or North Carolina privacy laws.
- I may refuse to sign this authorization and understand that my refusal to sign will not affect my ability to obtain treatment. If I refuse to sign this authorization, access to my Patient Portal account will not be granted.
By signing below, proxy acknowledges and agrees that:
- I will be using my own FollowMyHealth Patient Portal account to access the patient's Patient Portal account.
- As indicated, I have parental rights or legal guardianship rights to access this patient's record.
- I have not been denied periods of physical placement with the patient and there are no court orders or restraining orders in effect limiting my access to this patient's medical records and/or information.
- Communications on behalf of the patient through the Patient Portal must be sent from the patient's record and responses will be received in the patient's record. Patient Portal e-mail alerts will be sent to the e-mail address entered under "Proxy Information."
- For a child age 0-17 years, I will be granted full access to the Child's medical record, subject to NC law.
Legal Guardians:

Any documents, if any, I have provided in support of my right to access the patient's protected health information, are true and correct copies and are the most recent documents related to this matter. When my legal authority to act on behalf of the patient has been inactivated, revoked, terminated or expires, I must immediately notify MAHEC in writing of the change in authority and mail it to the Health Information Management Department.
Patient Signature: By signing below, I acknowledge and agree that I will comply with the terms and conditions contained in this document and understand that I can revoke this proxy access at any time by notifing MAHEC in writing.
Patient Signature*
I am an Adult/Emancipated Minor Authorizing Proxy Access to my account:*

Clear
Date*

MonthDayYear
Date
I am the Parent/Legal Guardian of the Patient Authorizing Proxy Access to his/her account:*

Clear
Relationship to Patient*
Date*

MonthDayYear
Date
Proxy Signature: By signing below, I acknowledge and agree that I will be using my own FollowMyHealth Patient Portal account to access the patient's Patient Portal account. I will comply with the terms and conditions contained in this document and understand the patient can revoke my access to his/her Patient Portal account at any time.

I am the Individual/Proxy receiving access to the Patient's account:
Proxy Signature Required*

Clear
Relationship to Patient Required*
Date*

MonthDayYear
Date
Legal ID must be attached*

Cancelof
Should be Empty:

Patient Portal Proxy Access

All Information is required to process your proxy authorization.

Patient Information

Proxy Information

Adult Patient

Minor Patient