Proxy Form - Avera Health Access To Records Page 2
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2PROX ACC
PROX ACC
Proxy:
I acknowledge and agree that:
•
The patient can revoke the proxy access to his/her AveraChart at any time.
•
If the patient is under age 12 years, proxy access will be deactivated on the patient’s 12th birthday.
•
If the patient is aged 12 – 17 years, proxy access will be deactivated on the patient’s 18th birthday.
•
I will comply with the terms and conditions on the AveraChart web page and this document.
•
When my legal authority to act on behalf of the patient has been inactivated, revoked, terminated or expired,
I must immediately notify AveraChart in writing of the revocation, termination or expiration and mail it to your:
Health facility, Attn: Health Information Management.
► ____________________________________/_____________________________/ _______________________
Proxy Signature
Relationship to Patient
Date
Patient:
I acknowledge and agree that:
•
I must have my own AveraChart.
•
I will comply with the terms and conditions on the AveraChart web page and this document.
•
I choose to designate the person named above as a proxy to my AveraChart, thereby allowing him/her
access to AveraChart protected health information, including but not limited to HIV/AIDS test results. I
authorize release of any information contained in my AveraChart medical record held by health facilities
utilizing AveraChart (a list of facilities can be found at ) to my designated proxy. I
understand that the medical information in AveraChart is obtained from my electronic medical record and
may include information from all facilities listed in the health facilities’ Notice of Privacy Practices.
•
I authorize release of this information only through my AveraChart record. This form does not authorize
release of my medical record to my designated proxy by other methods or in other forms.
•
I understand that once information has been disclosed, it potentially may be re-disclosed by the proxy and
the disclosed information may not be covered by federal privacy protections.
•
Participation in AveraChart and designating an AveraChart proxy is completely voluntary. I understand that
I am not required to designate an AveraChart proxy and I am not required to provide this authorization. I
also understand that the healthcare facility does not condition any of my health care treatment, payment or
other services on whether I provide this authorization. However, I also understand that if I do not provide
authorization, the healthcare facility is not permitted to provide access to my AveraChart to a proxy.
•
I understand that if I no longer want the proxy to have access to my AveraChart, I may revoke his/her access
in writing by sending a request to your: Health Facility, Attn: Health Information Management. A Proxy
Revocation form may also be found at .
•
I understand that if I revoke this authorization, my designated proxy’s access to my AveraChart will be
ended. I also understand my revocation will not affect any disclosures that were made prior to processing
the revocation request.
•
Unless proxy access is deactivated or otherwise revoked by patient, access shall be granted to proxy until
termination of patient’s AveraChart.
► ____________________________________/_____________________________/ _______________________
Patient Signature
Relationship to Proxy
Date
► ____________________________________/_____________________________/ _______________________
Signature of Legal Representative
Relationship to Proxy
Date
Patient signature not required when patient is under the age of twelve (12)
or proxy has legal authority. Please attach relevant document(s).
HIM use only (staff initials)
____Patient signature verified
Return forms to your:
____Approved by HIM
Health facility
____Proxy access granted
Attn: Health Information Management
____Form scanned into medical record
Proxy Access Form
Form 8691-140 (English) (Rev. 6/16) (FO)
Page 2 of 2
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