EFTA00313923.pdf

Adult MyChart at NItt. Lantone Proxy Access Request and Authorization Fenn Requirements and Procedures • Proxy access to the MyChan at NYU Langone record of an adult may be granted by the patient or his/her legal representative. • Both the person requesting access and the patient or his/her legal representative must sign this form. • The proxy must have his/her own MyChart at NYU Lango ne account because the patient's chart will be accessed through the proxy's MyChart at NYU langone record. I understand that: • MyChart at NYU Langone is intended as a secure online source ofconfidential medical information. • My-Chart at NYU Langone is not to be used in an emerg ency. • Use of MyChart at NYU Langone is voluntary and I am not required to authorize proxy access. • I must select a confidential password to maintain my passw ord securely and change my password if I believe it may have been compromised in any way. • Ill share my MyChart at NYU Langone ID and password with another person, that person may be able to view my or my child's health information, as well as information about any adult who has authorized me as a MyChart at NYU Langone proxy. • If I have proxy access. I must log in to my own MyChart at NYL' Langone account and click on "View Other Records" to access another patient's record. • MyChart at NYU Langone contains selected, limited medic al information from a patient's medical record and is not the complete medical record. • My activities within MyChan at NYU Langone may be tracked by computer audit and entries I make may become pan of the medical record. • Access to MyChart at NYU Langone is provided by NYC Langone Medical Center as a convenience to its patients and that NYU Langone Medical Center kis the right to deactivate access at any time for any reason. Completing this form will establish a MyChart at NYU Lango ne record for the patient and proxy. Return completed forms to your provider's office or to If you already have a MyChart at NYU Langone accoun you t, will receive a MyChart at NYU Langone message when access to the additional patient's record is available, typica lly 5 to 7 business days alter completed request and authorization form is received. PROXY: I am requesting access to the medical information available on MyChan at NYU Langone for the patient named below and agree to abide by the above terms and condit ions of MyChart at NYU Langone and all other terms and condition viewable online within MyChart at NYU Langone. Nalne: 1 -e PcIZei PSTEICale of Birth: fr O -53 Email: tC.Vet,C4.4\ COY) Address.'PhOne q ERS7 -4) ST ST, 0 14/ 04 1O02 I Proxy Signature Relationship to Patient Date PATIENT OR PATIENT REPRESENTATIVE: I acknow ledge that I have read and understand this Request and Authorization Form. I agree to its terms and choose to designate the person named above as my MyChart at NYU Langone Proxy. thereby allowing my proxy to access my MyChart at NYU Langone medical record. Name: Date of Birth: Address/Phone #: Patient or Representative Signature Relationship to Patient Date EFTA00313923