FORM A

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					FORM A                                               CLEVELAND CLINIC
                                                 MYCHART PROXY REQUEST FORM
                                                    (Required for Proxy Access)

Health Data Services, Ab-7                                                                                Office: (216) 444-2640
9500 Euclid Avenue                                                                                        Toll-free: (800) 223-2273 ext.42640
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Cleveland, OH 44195                                                                                       Fax: (216) 636-0991
Directions:
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Form A: MyChart Proxy Request Form: Must be completed with the requestor’s personal information if the requestor
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does not have an active My Chart account. (If the requestor has an active MyChart account, proceed to Form B for a Pediatric
Proxy Request Form or Form C for an Adult Proxy Request Form.)

Form B: MyChart Proxy Pediatric Access Request Form: Must be completed to grant My Chart Proxy Access to a
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pediatric patient’s account.

    Form C: MyChart Proxy Adult Access Request Form: Must be completed to grant My Chart Proxy Access to an adult
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    patient’s account.

    Upon receipt of completed form(s), acknowledgement of account activation will be mailed to requestor via U.S. Postal Service.
          A MyChart Account must be created to give caretaker’s
          access to their dependant loved ones information. The            Are you deaf? Yes_______         No_______
          following information must be provided to generate an
          activation code for MyChart.                                     Please select your preferred language:
                                                                             (If "other" please describe in comment section below.)

                                                                           English_______ Spanish_______ Other_______

                                                                           Comments________________________________
          Parent, Legal Guardian or Durable Power of Attorney for
          Healthcare:

          Requestor’s Name:_________________________________               Requestor’s SS#:_________________________________

          Requestor’s Cleveland Clinic #:_______________________           Requestor’s Date of Birth: _____ / _____ / ______



          Requestor’s Telephone #:____________________________             Requestor’s Current Street Address:

          Requestor’s Email:_________________________________              ______________________________________________


                                                                           ______________________________________________
                                                                           City              State      Zip Code

        ________________________________________________                  __________________
        Signature of Patient’s Personal Representative/Parent             Date



        Please submit Form by:
                                                Fax Number:                (216) 636-0991
                                                Mail:                      Cleveland Clinic
                                                                           Attn: My Chart Proxy Access Area
                                                                           Health Data Services Ab-7
                                                                           9500 Euclid Ave.
                                                                           Cleveland OH, 44195
                                                Drop off:                  Ab 131 (Basement of the A building)

                                                                  Revised 1/21/08
FORM C                                                CLEVELAND CLINIC
                                           MYCHART PROXY ACCESS REQUEST
                                               AUTHORIZATION FORM
                                                             ADULT
    Health Data Services, Ab-7                                                                Office: (216) 444-2640
    9500 Euclid Ave.                                                                          Toll-free: (800) 223-2273 ext. 42640
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    Cleveland, OH 44195                                                                       Fax: (216) 636-0991

    Patient’s Name:___________________________________            Patient’s SS#:_________________________________

    Patient’s Cleveland Clinic #:_________________________        Patient’s Date of Birth: _____ / _____ / ______

    Patient’s Telephone #:______________________________          Patient’s Current Street Address:

    Requestor’s E-mail:________________________________           _____________________________________________

                                                                  _____________________________________________
                                                                  City                State       Zip Code




    Name of Person Authorized to Have Access:

    __________________________________                            _________________________________
    Print                                                         Phone Number

    __________________________________
    Signature

    Please check the authorized party’s relationship to the patient:
    □ Legal Guardian **
    □ Durable Power of Attorney for Healthcare (DPOA) **
    □ Caregiver for Senior Patient (Both the patient and person requesting must sign below)

    **This request MUST be accompanied by a copy of legal paperwork verifying the authority of the patient’s personal
    representative (i.e. court appointed guardian, durable power of attorney for health care).

  As the patient’s personal representative, I hereby authorize Cleveland Clinic to release health information on the above
  patient via MyChart Proxy according to MyChart Proxy terms and conditions. I understand and acknowledge that this
  may include the patient’s treatment for physical and mental illness, alcohol/drug abuse, and/or HIV/AIDS test results or
  diagnoses. I understand that I may discontinue MyChart Proxy Access at any time by contacting the MyChart Customer
  Service Center. For this authorization to be valid, activation of the MyChart Proxy access feature must occur within sixty
  days from the date of this authorization.

  _____________________________________________                           _______________________
  Signature of Patient’s Personal Representative/Parent                    Date

 __________________________________________                                ______________________
  Signature of Patient (Required for senior caregiver request)            Date

 Please submit Form and Required Legal Documents by:

               Fax Number:               (216) 636-0991
               Mail:                     Cleveland Clinic
                                         Attn: MyChart Proxy Access
                                         Health Data Services, Ab-7
                                         9500 Euclid Ave.
                                         Cleveland OH, 44195
               Drop off:                 Ab-131 (Basement of the A building)

                                                           Revised 1/21/2008

				
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