Proxy for Minor Patient 13-17 Years of Age Express Waiver and Consent Instructions
The caregiver feature of MyHealthOne permits patients to grant access to their own MyHealthOne account so that others can view their health information. Caregivers should be trusted individuals and will be legally designated to access the patient’s health information.
To request caregiver permissions for a family member or loved one through MyHealthOne, or, permit someone else to have caregiver permissions for your MyHealthOne account, take the attached form to the hospital that the patient most recently visited. You will be required to complete and sign the form in the presence of a hospital representative at the patient registration, health information management, or medical records office.
If the patient is unable to sign the Waiver and Consent form, the patient’s Power of Attorney may sign on behalf of the patient. The Power of Attorney must present documentation and state-issued photo identification. If the patient is unable to sign the Waiver and Consent form but no Power of Attorney exists for the patient, then the caregiver or proxy enrollment cannot occur.
For patients aged 0-12
Please take the Proxy for Minor Patient 0-12 Years of Age Express Waiver and Consent to the hospital the minor patient most recently visited. A parent or legal guardian must present photo identification. Although anyone can be the caregiver or proxy, the Proxy for Minor Patient 0-12 Years of Age Express Waiver and Consent must be signed by the parent or legal guardian at the hospital’s registration desk.
For patients aged 13-17
Select a trusted individual as your caregiver. Please take the Proxy for Minor Patient 13-17 Years of Age Express Waiver and Consent to the hospital you most recently visited. A parent or legal guardian and the minor patient must both sign the Proxy for Minor Patient 13-17 Years of Age Express Waiver and Consent and present photo identification at the hospital’s registration desk.
For adult patients
Please take the Proxy for Adult Patient Express Waiver and Consent to the hospital you most recently visited. You will need to present photo identification at the hospital and be ready to provide information about your caregiver or proxy.
For the caregiver
All caregivers must be at least 18 years old, have an active email address, and present state-issued photo identification to the patient’s most recent hospital.
When the hospital has processed the form, please call the MyHealthOne support team at 1-855-422-6625 to complete the caregiver enrollment process.
For the hospital
As a hospital employee, if you have questions about this form, please call the MyHealthOne hospital Portal Support team. This form is also available on Atlas Connect.
Proxy for Minor Patient 13-17 Years of Age Express Waiver and Consent
The undersigned patient ("Patient") hereby grants to the undersigned parent or legal guardian of Patient ("Parent"), and Parent hereby requests to be granted, proxy access to Patient’s health and other information ("Patient Information") and understand that by doing so Patient waives all rights related to privacy and confidentiality of Patient Information with Parent (including, without limitation, the privacy practices of Putnam Community Medical Center). Patient represents and warrants that he or she is a minor with the ability to enter into agreements relating to the consent to access and waiver of rights involving highly sensitive medical data. Parent represents and warrants that he or she is the parent or legal guardian of the minor patient with the ability to enter into agreements relating to the consent to access and waiver of rights involving Patient’s medical data. Patient and Parent further understand and acknowledge that (a) Putnam Community Medical Center can rely on this waiver and consent until revoked by either Patient or Parent in writing; (b) by providing this waiver and consent Parent has no fewer rights to access Patient Information than Patient has; and (c) Patient and Parent waive all rights and remedies relating to Parent’s use or misuse of Patient Information that Putnam Community Medical Center provides Parent pursuant to this Express Waiver and Consent. Please note that if this waiver and consent is revoked, such revocation will not affect any action taken in reliance on this waiver and consent prior to such revocation. If either Patient or Parent wants to revoke this Proxy Express Waiver and Consent, he or she must call Patient Portal Support at 1-855-422-6625.
|Patient Name (Print):||Patient Medical Record Number:|
|Patient Account Number:||Patient/Authorized Patient Representative Signature:|
|Date of Consent:|
|Proxy Name (Print):||Proxy Email Address:|