Authorization for Proxy Access to My Health Agreement

Authorization for Proxy Access to My Health Agreement

This form must be completed, signed and returned to request access to My Health to help manage the medical care of a patient 13 years of age and older.
Patient Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Proxy Information (Person requesting access to My Health)

I authorize the following individual to participate in My Health as my proxy:
Name

First NameLast Name
Email
(Please supply the email address of the person who will be using My Health)
I understand that my proxy will have the same access and privileges that I have for My Health. I understand that this allows my proxy online access to all of my personal health information, including any mental health information, HIV/AIDS information, and substance abuse information that may be included in my medical records at St. Anthony Regional Hospital and Manning Regional Healthcare Center. My proxy will be able to view, print, and download portions of my record. I also understand that additional information may be made available to my proxy through My Health as St. Anthony Regional Hospital and Manning Regional Healthcare Center continue to implement this product.

By signing this authorization, I am requesting St. Anthony Regional Hospital and Manning Regional Healthcare Center give access to my proxy to utilize My Health.

I understand that St. Anthony Regional Hospital and Manning Regional Healthcare Center will require my proxy to sign an acknowledgment and agree to St. Anthony Regional Hospital and Manning Regional Healthcare Center policies and procedures for use of the patient portal.

I understand that St. Anthony Regional Hospital and Manning Regional Healthcare Center may not condition treatment or payment actions on whether I sign this authorization. This authorization is valid until revoked by me or upon my death. I understand that a written request is necessary to revoke or cancel this authorization, but in the case of death, this authorization will automatically expire. In order to revoke or cancel my authorization I must send such request in writing to St. Anthony Regional Hospital, ATTN: ANALYSTS, 311 S. Clark St., Carroll, IA 51401. However, I understand that my revocation will not be effective as to uses and/or disclosures already made in reliance upon this authorization. I realize that the information used and/or disclosed pursuant to this authorization may be subject to re-disclosure and no longer protected by federal privacy laws. I acknowledge that a copy of this signed authorization has been provided to me.
PART B: Proxy Information (Person requesting access to My Health):
Signature of Patient
Signature of Proxy
Should be Empty:

Authorization for Proxy Access to My Health Agreement

Patient Information

Proxy Information (Person requesting access to My Health)

PART B: Proxy Information (Person requesting access to My Health):