MyChart MVHC Proxy Form

Complete this entire form to gain access to another patient's MyChart record.

To sign up for access to another patient's MyChart record, please complete all sections of this form. Please note that the requested patient's chart will be accessed through your own MyChart record.

Forms will be returned by email to:
Muskingum Valley Health Centers: medical-records@mvhealthcenters.org
2725 Pinkerton Road Zanesville, OH 43701

Your name:*

Your date of birth:*

Date

Phone:*

Address:*

Patient name:*

Patient date of birth:*

Date

Relationship to Patient:*

ParentLegal Guardian

Description of Proxy Levels:
Parent - Child, for Children ages 0-12
Thie proxy has full access to the child's MyChart account. This access is termed once the child turns 13, and a new proxy teen form must be completed.

Parent - Teen, for Children Ages 13-17
The proxy can view demographic information only, but cannot access clinical details or edit the account. This access is termed once the child turns 18, and the adult proxy form must be completed.

Adult to Adult
This level of proxy access needs to be completed directly through each adults MyChart accounts, under the Sharing tab. If you have any questions text 740-891-9000, or call 740-962-1668.

Type of Proxy Access Requested:*

Parent - Child, for Children Ages 0-12Parent - Teen, for Children Ages 13-17

I understand that MyChart is intended as a secure online source of confidential medical information. If I share my MyChart ID and password with another person, that person may be able to view my or my teen’s health information, and information about someone who has authorized me as a MyChart proxy. I agree that it is my responsibility to select a confidential password, to maintain my password in a secure manner, and to change my password if I believe it may have been compromised in any way. I understand that MyChart contains selected, limited medical information from a patient’s medical record and that MyChart does not reflect the complete contents of the medical record. I also understand that a paper copy of a patient’s medical record may be requested from my physician’s office. I understand that my activities within MyChart may be tracked by computer audit and that entries I make may become part of the medical record. I acknowledge that I have read and understand this MyChart Proxy Form. I agree to its terms and gained permission from the person named above to be a MyChart Proxy, thereby allowing me access to their MyChart medical record.

By signing below, I confirm that I have read and agree to the terms and conditions listed above, and that the information I have provided is accurate and truthful.

Signature of Person requesting Proxy Access*

Audit Email

example@example.com