myDH - Request for Adult Proxy

To request access to another adult's electronic medical record, acting as a “personal representative” of the individual as permitted by HIPAA, please complete and submit this request form. Additional information such as the Designation of Personal Representative form may be required and, if so, you will be contacted by a member of the Health Information Services Department. Their record will be accessed through your myD-H account.

Items marked with a red * are required.

Person Making Request:

Your First Name:

Your Last Name:

DOB:

Last 4 digits of SSN:

Sex:

Your contact information:

Your Email:

Confirm Email:

Phone:

Cell Phone:

Address:

City:

State:

ZIP:

Requesting access to adult:

First Name:

Last Name:

Sex:

DOB:

Adult's contact information:

Address:

City:

State:

ZIP:

Phone:

Additional information:

This adult is your:

If other, please specify:

I certify that I have the legal right to this adult's medical information.