Name: | DOB: | MRN: | PCP:

MyCarle Proxy Form

Please be aware Foster Parents are not granted proxy access for minors under the age of 12.

Patient Information
All fields are required.

Please enter patient's first and last name.

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

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

Please enter the date of birth for the patient.

Please provide the patient's home address.

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

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?
Which age group are you requesting a proxy change for?
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.

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

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

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

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

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