MyChart -

This form only requests the release of information through MyChart, a patient portal for Stamford Health, Inc. It does not include the release of records by any other means. Please note that the person requesting proxy access must create their own MyChart account in order to have access to the patient’s information.

Patient Information - Whose MyChart do you want access to?

Name:

Date of Birth:

Address:

City:

State:

Zip:

Email:

Phone:

Proxy Information: Please fill in your information below.

Proxy Name:

Date of Birth:

Address:

City:

State:

Zip:

If family, please describe relationship:

If other, please describe relationship:

I hereby request proxy access to the MyChart account of the above-listed patient who is (check one):

Minor under the age of 13Minor over the age of 13Adult who lacks capacity

I understand that:
◆ I will have access to all of the patient’s information that is included in the patient’s MyChart account (e.g., lab results, medications, progress notes).
◆ If I am a parent of a child under the age of 13, this proxy access will cease when my child turns 13 and I will have limited access, please see FAQs page for more information on this.
◆There may be information in the patient’s medical record that is not included in the patient’s MyChart account. If I wish to obtain a complete copy of my medical record, I will need to contact Stamford Health's Health Information Management department.
◆If I am granted proxy access, I am expected to protect the confidentiality of the patient’s information in the same way that I would protect my own.
◆Stamford Health may terminate this proxy access at any time at its sole discretion.

Request Proxy Access

Patient Information - Whose MyChart do you want access to?

Proxy Information: Please fill in your information below.