Get And Sign Adult Proxy TemplateDoctors Hospital 2018-2021 Form

Completed by the adult patient who is authorizing another adult to access health information in his or her interactive health record. It must accompany the Adult Proxy Form which provides the name and information of the individual who the patient is authorizing to access their interactive health record as a proxy. Name last first middle initial Last 4 digits SSN Date of birth Street address City State Zip Email address Phone number Check the box next to the organization that provides your...