• Authorization for Access to My Health

    Use this form to request access to view another person’s medical record via My Health. You will need to obtain the proper information, including signatures, to obtain access from a patient who is 13 years of age or older.

  • PART A: Proxy Information (Individual requesting access)

  • If yes, please provide your name, date of birth, username and skip to Part B.

  • Date of Birth
     - -
  • Format: (000) 000-0000.

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

  • You will need to complete this form for each individual you are requesting proxy access for. All patients, age 13 and over, must sign a separate form (Authorization for Proxy Access to My Health Agreement) to grant access. This information will be reviewed, and St. Anthony or Manning may contact the patient to confirm permissions. All requests for proxy access to minors over the age of 13 will be automatically denied unless the minor signs the Authorization for Proxy Access to My Health Agreement. Existing proxy access for minors under age 13 will automatically be revoked on the minor’s thirteenth birthday unless the minor signs the Authorization for Proxy Access to My Health Agreement. Patients may revoke proxy access at any time.

  • Date of Birth
     - -
  • Should be Empty: