There are circumstances when a patient may want someone else to be able to obtain or provide medical or financial information on their behalf.
In keeping with HIPAA (Health Insurance Portability and Accountability Act) privacy and security requirements, special consents and authorizations are available at Registration for your convenience or you may download them below and bring the completed
forms with you when you arrive for your appointment.
Here are some situations that may apply to you.
Consent for Proxy Access to MyChart
Adults may have a family member, loved one or caregiver who they would like to grant access to their MyChart Account. To do this, sign in to your own MyChart account and click the My Family’s Records link on the My Account tab. Then click the
Grant an adult access to your record link. Fill out the form and click Submit Request. You and your proxy will be contacted within 2 business days to complete the request. In cases of diminished capacity
of the patient, the proxy can request access using the Request for Proxy Access to MyChart form. The patient MUST have legal documentation of the proxy’s right to access their medical records on file (i.e. durable power of attorney).
Download: Request for Proxy Access to MyChart (English) >
Release of Clinical Information
Adults may have a family member, loved one or caregiver who makes their appointments or calls for medical concerns on their behalf. These representatives must be identified by the patient and documented in the patient records so our medical and support
staff can provide medical information to them. For patient convenience, Sansum Clinic provides "Consent to Disclose Protected Health Information to a Designated Patient Representative" form.
Download: Consent to Disclose Protected Health Information to a Designated Patient Representative (English) >
Download: Consent to Disclose Protected Health Information to a Designated Patient Representative (Español) >
Release of Billing Information
Patients may have someone assisting them with their financial matters. These representatives must be identified by the patient and documented in the patient records so our medical and support staff can provide billing information to them. The completion
of the "Patient Consent for Release of Billing Information" form will permit our Billing Staff to speak directly with the person regarding your financial matters with Sansum Clinic.
Download: Patient Consent for Release of Billing Information >
Medical Release Forms
This form, which is also available in Spanish, is necessary for the inspection or copying of a patient’s medical records. Release of patient medical information requires completing a "Authorization for Use/Disclosure of Protected Health Information"
form. There is no charge for forwarding health information to other providers including those outside Sansum Clinic.
Download - English: Authorization for Use/Disclosure of Protected Health Information (English) >Download - Spanish: Authorization for Use/Disclosure of Protected Health Information (Español) >