UCSF Medical Center – MyChart Proxy Authorization Form

Important Reminder: UCSF MyChart displays certain information from medical records, but it does not display all health information in medical records. To secure all health information, contact Health Information Management 415-476-9000

Parent/Legal Guardian of Adolescent: This authorization form is used to establish UCSF MyChart accounts for both the Parent/Legal Guardian and the adolescent patient. This authorization form serves as acknowledgement and permission for my adolescent to have a UCSF MyChart account. Legal papers establishing parental or guardian relationship may be requested. A renewal of this authorization may be requested as well. Expiration of proxy access automatically occurs on the patient's 18th birthday.

AGREEMENT –

The UCSF Medical Center (UCSFMC) Terms and Conditions for UCSF MyChart, and the UCSF MyChart Proxy/Disclaimer for access to My Family’s Record in the UCSF MyChart section control this agreement between the patient’s parent/legal guardian and UCSF Medical Center. Please refer to these documents when you signup online.

YOUR RIGHTS

This Authorization to release health information is voluntary. You may revoke proxy access at any time. For revocation, please contact the patient’s practice. The Revocation will take effect within 2 business days upon notification of your request except to the extent UCSF Medical Center or others have already relied on it. d text

REVOCATION/EXPIRATION OF AUTHORIZATION

Unless otherwise revoked, or ended by revocation, authorization for UCSF MyChart proxy access will not expire unless the relationship between the legal guardian and the patient changes.

If the parent/guardian is a UCSF patient

If the parent/guardian is NOT a UCSF patient

I attest that the above information is true and correct.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

UCSF Medical Center Practice Representative who witnessed this proxy:

Parent/Legal Guardian Proxy – ADOLESCENT (12-17 years)

Dear Parent/Guardian,

Thank you for signing the UCSF MyChart Proxy Authorization form. This is the first step in allowing you to view some of your adolescent’s health information online through UCSF MyChart patient portal.

UCSF MyChart patient portal is offered to you free of charge as an online resource for routine health care needs. For patients age 12-17, UCSF requires signed approval from the parent or guardian in order for the parent/guardian to view some of the child’s health information on MyChart. Proxies would have access to adolescent test results, allergies, and immunizations; they can message their adolescent’s providers and request appointments on their adolescent’s behalf. Parents/guardians will not have access to information related to sensitive services, such as reproductive health (i.e. pregnancy testing, contraception, testing and treatment for sexually transmitted diseases), and certain mental health and substance use screening and treatments. Because certain sections may contain sensitive information, parent proxy access will be limited as follows:

Once your child turns 18, you will be removed from their account and will not see any of their health care information. If you have any questions, please call the patient’s practice or UCSF MyChart Customer Service at 415-514-6000 (M-F 8 am -5 pm) or email us at UCSFMyChart@ucsfmedctr.org

This is what you will see when you are successfully linked to the UCSF MyChart account:

We look forward to continuing to provide you with your family’s health care needs.