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MyChart Sign-up on Behalf of an Adult Family Member

Proxy Legal Guardian Information:

First Name *

Last Name *

Last Four Digits of SSN

Date of Birth*

Gender*

Male Female

Street Address*

City*

State*

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip*

Home Phone Number*

Email Address*

Relationship to Patient*

Spouse Son/Daughter Brother/Sister Other Relative Legal Guardian

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Patient Information:

First Name *

Last Name *

Last Four Digits of SSN*

Date of Birth*

Insurance Provider*

Primary Care Physician*

Address (If different from legal guardian)

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I am requesting this access with the permission of the patient listed. I understand my access can be terminated by the patient at any time for any reason.* I certify that I am the legal guardian of the patient listed here.

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