Patient Portal -

Please be aware Foster Parents are not granted proxy access for minors 17 years of age and under.

Patient Information

All fields are required.

Enter patient's legal name

Please enter patient's first and last name.

Patient MRN

Please enter patient's medical record number for your account with the organization.

Last 4 digits of patient's SS#

Please enter the last 4 digits of the patient's Social Security Number (SSN).

Patient's Date of Birth

Please enter the date of birth for the patient.

Patient's Home Address

Please provide the patient's home address.

City

Please enter the city of the patient's home address.

State & ZIP

Please enter the State and ZIP code for the patient's home address.

Telephone (Include Area Code)

Please provide the patient's telephone number including your area code in the format ###-###-####.

Proxy Action?

What action would you like take for your proxy request?

Action?

Authorize AccessRevoke Access

Which age group are you requesting a proxy change for?

Child (Birth through 11 years of age) - Form to be completed by Parent/Legal GuardianAdolescent (12 through 17 years of age) - Form to be completed by PatientAdult (18 and older) - Form to be completed by Patient

Name to be Authorized/Revoked

Please provide the information for the individual that you would like to be either revoked or authorized for proxy access.

Proxy Name

Please provide the name of the proxy who should be authorized or revoked access.

Proxy Date of Birth

Provide the date of birth for the proxy who should be authorized or revoked access.

Last 4 digits of Proxy SS#

Proxy Address

Please provide the street address for the proxy to authorize or revoke access.

City of Proxy

Please provide the city of the proxy's home address who should be authorized or revoked access.

State & ZIP of Proxy

Please provide the state and ZIP code for the proxy's home address who should be authorized or revoked access.

Proxy Telephone (Include Area Code)

Please provide the telephone number for the proxy who should be authorized or revoked access in the format ###-###-####.

Authorization Signature

By agreeing below, you are certifying that you are the patient and are either authorizing someone else to have proxy access to your medical record or revoking proxy access. If you are permitting another individual to have proxy access to your medical record, you understand that any individuals with proxy access to your medical record may have the ability to see any sensitive encounters or results that are visible in your MyCarle account. These records may include, but are not limited to, documentation related to your receipt of behavioral health services, HIV status, sexually transmitted disease testing or results, and/or genetic information. The proxy will have access to your medical information until such access is revoked. If you should desire to revoke this access in the future, you can do so by either clicking revoke on the proxy request page in MyCarle or filling out a revoke request form.

Authorization

I have read and understand the above information and hereby request removal or authorization to the above-named patient's MyCarle online account.

Printed Name of Patient or Parent/Legal Guardian

Date of Authorization

MyCarle Proxy Form