Medical Records Proxy Access Form
Request proxy access to a person's medical records. Please complete all required fields accurately.
Requester Full Name
*
First Name
Last Name
Requester Email Address
*
example@example.com
Requester Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Relationship to the Patient
*
Please Select
Parent/Guardian
Spouse/Partner
Child
Legal Representative
Other
Scope of Access Requested
*
Reason for Proxy Access (optional)
By signing below, I authorize the above request for proxy access to medical records.
*
Submit Request
Submit Request
Should be Empty: