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It explains that both the proxy and the patient must sign the access form, and the patient must also sign a separate medical information release authorization. The form requires two identification documents for both individuals, including a government-issued photo ID and proof of current address, and provides submission addresses or fax destinations. 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A person who is granted access to another adult’s medical record is called a “CareGiver” or \"Proxy.” In order to become a Proxy, both the Proxy and the patient must sign this form. In addition, the patient must sign a separate authorization for release of medical information to the Proxy (called the “Adult Care/Giver Proxy Authorization Form”) .  \nPlease note that portions of the patient’s chart will be accessed through your (the Proxy’s) MyChart record. Completing this form will establish a MyChart record for you (if you currently do not have a MyChart account) and for the patient.  \nYou must include two forms of identification ,* for both yourself and the patient, one of which must be a government issued photo ID and an additional one that is proof of your current address.  \nReturn all forms to HMH Health Information Department at:  \n\n| Hackensack University Medical Center, Health Information Dept. , 30 Prospect Ave, Hackensack, NJ 07601 OR Fax: 201-489-0591 | Jersey Shore University Medical Center, Health Information Department, 1945 Route 33, Neptune, NJ 07753 OR Fax: 732 776-4692 | Raritan Bay Medical Center, Health Information Department , 530 New Brunswick Avenue, Perth Amboy, NJ 08861 OR Fax:732 324-4883 |\n| --- | --- | --- |\n| Bayshore Medical Center, Health Information Department, 727 North Beers St , Holmdel, NJ 07733 OR Fax: 732 888-7332 | Ocean Medical Center, Health Information Department, 425 Jack Martin Blvd, Brick, NJ 08724 OR Fax: 732 840-9616 | Palisades Medical Center, Health Information Management, 7600 River Road North Bergen, NJ 07047 OR Fax: 201-854-8360 |\n| Riverview Medical Center, Health Information Department, 1 Riverview Plaza, NJ 07701 OR Fax: 732 224-7210 | Southern Ocean Medical Center, Health Information Department, 1140 Route 72, Manahawkin, NJ 08050 OR Fax: 609 978-8965 | John F Kennedy Medical Center, Health Information Management, 80 James St. , Edison, NJ 08820 OR Fax: 732-744-5639 |\n\nPerson Seeking Access / Proxy (All sections required – please print clearly)  \nThis section should be completed by the individual requesting access to another adult’s MyChart record.  \nName (last, first, middle initial):  Date of Birth:    \nStreet Address:   City:   State:   Zip:  Email Address:   Home Phone Number:   Have you received any services at Hackensack Meridian Health facility/provider? YES   NO  \nPatient (All sections required – please print clearly)  \nComplete this section with information about the patient whose MyChart record the Proxy is requesting access.  \nName (last, first, middle initial):  Date of Birth:   Street Address:   City:   State:   Zip:  Email Address:   Home Phone Number:    \nMyChart Terms and Agreement  \n• I understand that MyChart is intended to provide limited access to confidential medical information. If I share or allow my MyChart ID and password to be disclosed to another person, that person may be able to view my health information, and information about someone who has authorized me as a MyChart Proxy and transmit that information to a third party.  \n• I agree that it is my responsibility to select a confidential password, to maintain my password in a secure manner, and to change my password if I believe it may have been compromised in anyway.  \n• I understand that MyChart contains selected, limited medical information from a patient’s medical record and that MyChart does not reflect the complete contents of the medical record. I also understand that a paper copy of a patient’s medical record may be requested from the HMH Health Information Departments at the locations listed above (phone numbers provided on page 2 in box) .  \n• I understand that access to MyChart is provided by Hackensack Meridian Health as a convenience to its patients and that Hackensack  \nMeridian Health has the right to deactivate acces","cbCaif7VBmISir4g","https://ap.wps.com/l/cbCaif7VBmISir4g","pdf",286248,"English","# Authorization Granting Access to MyChart Medical Record\n## Proxy/Person Seeking Access Information\n## Patient Information\n## MyChart Terms and Agreement\n## Signatures\n# Adult CareGiver/Proxy Authorization Form","[{\"question\":\"Who must sign the MyChart Adult CareGiver/Proxy Form?\",\"answer\":\"The proxy (caregiver/proxy) and the patient must both sign the form in order for the proxy to gain access to the patient’s MyChart record.\"},{\"question\":\"What additional authorization is required besides this proxy form?\",\"answer\":\"The patient must sign a separate authorization for release of medical information to the proxy.\"},{\"question\":\"What identification documents are required?\",\"answer\":\"Two forms of identification are required for both the proxy and the patient, including a government-issued photo ID and an additional document proving the current address.\"}]","MyChart Adult CareGiver/Proxy Form - Authorization Granting Access to Medical Record | PDF",1791850287]