Adults Granting MyChart Proxy Access to Other Adults

If you are an adult patient (18 years or older) or a legally emancipated minor, you may grant proxy access to allow another adult, such as a family member or caregiver, to access your MyChart account.

What You Should Know Before Granting Proxy Access

Once your health information is sent to your account, you own that information, and you are responsible for safeguarding it. If you choose to grant proxy access, understand that:

• Your MyChart account may contain sensitive information, such as information related to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), behavioral or mental health services, treatment for alcohol or drug abuse, developmental disabilities and genetic testing results.
• Read-only proxy access will enable the person you designate to view all information in your account, including any potentially sensitive information as mentioned above.
• Full proxy access will enable the person you designate to view all information in your account and perform actions on your behalf, such as requesting appointments or prescription renewals, sending or receiving secure messages, transmitting your information electronically, adding health maintenance information and granting or revoking proxy access to others.
• You may revoke proxy access at any time. However, that person may already have viewed, transmitted or made copies of your information. Therefore, it may not be possible to further safeguard your information by revoking proxy access.
• The person you designate as a proxy is not covered under HIPAA and is not subject to federal health information privacy laws. Therefore, a proxy could further disclose health information and it may no longer be protected by law.

Supporting Documentation

Emancipated minors must show proof that they are legally emancipated in addition to completing this form. Supporting legal documents must be scanned and saved in the patient's medical record.

How to Apply

To grant proxy access to another person, complete Form EMR04139 and mail it or fax it, along with any required supporting documentation, to:

Health Information Management
4000 Wellness Drive
Midland, Michigan 48670
Fax (989) 839-3035

Or you may take it to the participating provider's office or Medical Center where you receive your care.