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The form lists proxy identity and contact details and specifies categories of information such as secured messaging, appointments, test results, medications, allergies, immunizations, preventive care, medical history, admissions tracking, billing and insurance, account letters, and current health issues. It explains revocation options, possible redisclosure risks, voluntary nature, validity until revoked, expiration expectations, and patient and submission instructions.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-for-adult-proxy-access-to-mychart-updated-11-29-2021/563390/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorization-for-adult-proxy-access-to-mychart-updated-11-29-2021/563390.png","ImageObject",442,249,{"name":88,"@type":89},"Blue Pony","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-19","2026-10-12",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who can the patient authorize to access MyChart as a proxy?","Question",{"text":109,"@type":110},"The patient authorizes a designated personal representative (Proxy) to access specified portions of electronic protected health information in Duke MyChart.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What kinds of information can the proxy view in Duke MyChart?",{"text":114,"@type":110},"The form authorizes access to clinical and billing information, including secured messaging, appointments, test results, medications, allergies, immunizations, preventive care, medical history, hospital admission tracking, billing & insurance, my account letters, and diagnosis/current health issues.",{"name":116,"@type":107,"acceptedAnswer":117},"How can the patient revoke the proxy authorization?",{"text":118,"@type":110},"The patient may revoke access at any time by clicking “Revoke access” within the Duke MyChart account section “My Family’s Records,” or by requesting revocation from a provider or contacting Duke Medicine Health Information Management by phone or written notice. Revocation does not affect disclosures made before revocation.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},563390,1792123266,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},962090760266,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Patient Name:    \nDate of Birth:    \nMedical Record \\#:   \nAuthorization for Adult Proxy Access to MyChart (updated 11-29-2021)  \nI authorize and request Duke University Health System* and Private Diagnostic Clinic PLLC* (“Duke”) to grant my designated personalrepresentative identified below (Proxy) access to portions of my electronic protected health information, including, clinical and billing information, maintained through Duke MyChart.  \n\n| Proxy Name Date ofBirth | Email |  |\n| --- | --- | --- |\n| Street Address City | State | Zip Code |\n| Electronic Protected Health Information in Duke MyChart |  |  |\n| Secured Messaging Appointments | Test Results | Medications |\n| Allergies Immunizations | Preventive Care | Medical History |\n| Hospital Admission Track My Health | Billing & Insurance | My Account Letters |\n| Diagnosis Current Health Issues |  |  |\n| I Understand That\u003Cbr>􀁸 Information to be released in Duke MyChart may include mental health, substance abuse or STD diagnosis, treatment or medications\u003Cbr>􀁸 I may revoke this proxy authorization at any time by clicking the “Revoke access” button while logged into my Duke My Chart account, byaccessing the section titled “My Account,” and then opening the sub-section titled\u003Cbr>”My Family’s Records,“where I will see a list titled “Who can view my record?” I can also ask my provider to revoke this access, I cancall Duke Medicine Health Information Management at 919-384-7119 or I can send written notice to DUHS Health Information Management, Box 3016, Durham, NC 27710. Such revocation shall not affect disclosures prior to the revocation.\u003Cbr>􀁸 Information disclosed pursuant to the authorization may be subject to redisclosure by the Proxy and may no longer be protected by theHIPAA Privacy Rule.\u003Cbr>􀁸 This authorization is voluntary. If I do not sign or I revoke this authorization, Duke will still provide treatment to meand will seekpayment for services provided.\u003Cbr>􀁸 This authorization is valid unless and until I revoke the Proxy’s access. |  |  |\n| Expiration\u003Cbr>I understand that Duke MyChart access is a privilege, not a right, and that my Proxy must agree to comply with the Duke MyChart Terms and Conditions. DUHS will provide my Proxy an activation code and instructions for accessing electronic protected health information about me in Duke MyChart. If my Proxy does not accept and at all times comply with the Terms and Conditions, I understand that DUHS may deny my Proxy access or revoke my Proxy’s access Duke MyChart. I also understand that Duke may deny my Proxy access or revoke my Proxy’s accessfor any reason and at any time in Duke’s sole discretion. |  |  |\n|  |  |  |\n\nSignature of Patient Date  \n*All references herein to “Duke” shall refer to Duke University Health System, Inc., Duke University and any and all of its controlled affiliates, including without limitation Duke University Affiliated Physicians, Inc., d/b/a Duke Primary Care and Associated Health Services, Inc. and Private Diagnostic Clinic, PLLC and any and all ofits controlled affiliates including without limitation Regional Anesthesia, PLLC and Regional Psychiatry, PLLC.  \nCOMPLETED FORM should be returned to:  \nDUHS Health Information Management  \nE-mail [to](to ROI-Requestor3@duke.edu)[ ](to ROI-Requestor3@duke.edu)[ROI-Requestor3@duke.edu](to ROI-Requestor3@duke.edu)  \nMail to DUMC 3016, Durham, NC 27710  \nFax to 919-384-7148","cbCaipvhVrTbZi0A","https://ap.wps.com/l/cbCaipvhVrTbZi0A","pdf",155316,"English","# Patient and Proxy Information\n# Authorized Information in Duke MyChart\n# Revocation, Redisclosure, and Voluntary Authorization\n# Expiration and Terms and Conditions\n# Signature and Submission Instructions","[{\"question\":\"Who can the patient authorize to access MyChart as a proxy?\",\"answer\":\"The patient authorizes a designated personal representative (Proxy) to access specified portions of electronic protected health information in Duke MyChart.\"},{\"question\":\"What kinds of information can the proxy view in Duke MyChart?\",\"answer\":\"The form authorizes access to clinical and billing information, including secured messaging, appointments, test results, medications, allergies, immunizations, preventive care, medical history, hospital admission tracking, billing \\u0026 insurance, my account letters, and diagnosis/current health issues.\"},{\"question\":\"How can the patient revoke the proxy authorization?\",\"answer\":\"The patient may revoke access at any time by clicking “Revoke access” within the Duke MyChart account section “My Family’s Records,” or by requesting revocation from a provider or contacting Duke Medicine Health Information Management by phone or written notice. Revocation does not affect disclosures made before revocation.\"}]","Authorization for Adult Proxy Access to MyChart - updated 11-29-2021 | PDF",1791831114]