[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-565284-105":53,"doc-detail-565284-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","request-for-proxy-access-to-adults-mychart-account-form","REQUEST FOR PROXY ACCESS TO ADULT’S MYCHART ACCOUNT - Form","","Request for Proxy Access to an adult’s MyChart account form authorizes a caregiver, legal guardian, or specifically authorized adult to view and manage an adult patient’s confidential medical record online. The patient must sign and provide authorization for release of medical information; if the patient cannot sign, guardianship or healthcare power of attorney documentation is required. Proxy and patient details, acknowledgments about sensitive data disclosures, and a 45-day activation requirement are included.",{"@graph":63,"@context":118},[64,80,101],{"@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/request-for-proxy-access-to-adults-mychart-account-form/565284/",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/request-for-proxy-access-to-adults-mychart-account-form/565284.png","ImageObject",442,249,{"name":88,"@type":89},"Jasmine","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-16","2026-10-13",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who can request proxy access to an adult’s MyChart account?","Question",{"text":108,"@type":109},"Caregivers, legal guardians, or specifically authorized adults may request access to help manage the adult’s medical care.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What must the adult patient do for the request to be valid?",{"text":113,"@type":109},"The patient must sign the form and provide authorization for release of medical information in MyChart.",{"name":115,"@type":106,"acceptedAnswer":116},"How long does the proxy access request remain valid?",{"text":117,"@type":109},"The request expires in 45 days if the MyChart account is not activated within that time period.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},565284,1792122836,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":73,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},2336478487870,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Return completed forms to:  \n150 Bergen Street, B417  \nNewark, New Jersey 07103-2425 (973) 972-5608  \nScan into patient record once completed  \nREQUEST FOR PROXY ACCESS TO ADULT’S MYCHART ACCOUNT  \n(please print clearly)  \nWe are pleased to offer caregivers, legal guardians or specifically authorized adults online access to the medical record of another adult whose medical care they help manage. To request access, please complete this form. The patient must sign this form and provide authorization for release of medical information in MyChart. If the patient is not competent to sign on his/her own behalf, we will require documentation of guardianship or a power of attorney for healthcare decisions.  \nPatient’s Name: Birth Date:  \n_____________________________________________________________ ________________________  \n(first) (m. initial) (last)  \nAddress:   Phone \\#:    \n(street address)  \n  Medical Record \\#:    \n(city) (state) (zip code)  \n• I understand that the health information included in MyChart may include information considered very personal, including information about sexually transmitted and other communicable diseases, drug and alcohol abuse, HIV/AIDS, and mental health services. My health care provider, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.  \n• I understand that this authorization will continue until revoked. I may revoke this authorization by written request at any time by contacting my provider or the University Hospital Release of Information Department.  \n• I understand that the revocation will not apply to the Information that has already been released in response to this authorization.  \n• I understand that failure to comply with the MyChart Terms and Conditions may result in the termination of MyChart access privileges.  \n• I understand that my provider will not condition treatment on my signing this authorization.  \n• I understand this authorization must be filled out completely and signed and dated A copy that has not been altered will he considered as valid as the original.  \n• I acknowledge that I have read and understand this Adult Proxy Access form and that the full MyChart Terms and Conditions are available tome online. I agree to its terms and choose to designate the person named below as my MyChart Proxy, thereby allowing them access to my MyChart.  \nSignature of Patient Relationship to patient Date  \n(or authorized person) (if applicable)  \nProxy’s Information (Adult requesting access)  \n(All information is required-please print clearly. )  \nName:   Birth Date:   Last 4 Digits of SSN:  (first) (m. initial) (last)  \nAddress:    \n(street) (city) (state) (zip)  \nPhone Number:   Email Address:    \nRelationship to Patient: q Spouse q Adult Child q Caregiver q Legal Guardian  \nq Durable Power of Attorney for Healthcare q Other:    \nAre you also a patient with us? q Yes q No If yes, do you have a MyChart account? q Yes q No  \nFor Adult Proxy requesting access to another adult’s MyChart medical record:  \n• MyChart is intended as a secure online portal for viewing confidential medical information. I will not share my MyChart username and password with others. I understand that if I share my username and password with another person, that person may be able to view the patient’s medical information  \n• 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 any way.  \n• I have read and understand the information about proxy access for MyChart and have access to MyChart Terms and Conditions online  \n• I request access to the above patient’s MyChart account.  \nThis Request will expire in 45 days if you have not activated the MyChart account within that time period.  \nAccessing Adult Signature (Proxy) Relationship to Patient Date  \nPlease inclu","cbCaiueoOyk4OV40","https://ap.wps.com/l/cbCaiueoOyk4OV40","pdf",230899,"English","# Adult Proxy Access Request\n## Patient Authorization Section\n## Proxy Request and Acknowledgments\n## Expiration, ID, and Attachments","[{\"question\":\"Who can request proxy access to an adult’s MyChart account?\",\"answer\":\"Caregivers, legal guardians, or specifically authorized adults may request access to help manage the adult’s medical care.\"},{\"question\":\"What must the adult patient do for the request to be valid?\",\"answer\":\"The patient must sign the form and provide authorization for release of medical information in MyChart.\"},{\"question\":\"How long does the proxy access request remain valid?\",\"answer\":\"The request expires in 45 days if the MyChart account is not activated within that time period.\"}]","REQUEST FOR PROXY ACCESS TO ADULT’S MYCHART ACCOUNT - Form | PDF",1791850642]