PATIENT PORTAL PROXY AUTHORIZATION Using Foundation Health Partner’s (FHP) Patient Portal on behalf of another person is called Proxy access. Proxy access allows the designated user to access another person's medical record through their own account. If you use proxy access, you can authorize individuals to view your health information in FHP’s Patient Portal. Proxy users will need a personal FHP Patient Portal account in order to have proxy access to another person’s medical record. Patient Information Question Title * Please Enter Patient or Minor Child Name (First, Middle, Last). Please enter NMN if no middle name. Question Title * Please Enter Patient or Minor Child Date of Birth Date of Birth Date Question Title * Please Enter Patient or Minor Child Age Question Title * Please enter Patient or Minor Child Address Proxy User Information Question Title * Proxy User Name (First, Middle, Last). Please enter NMN if no middle name. Question Title * Proxy User Date of Birth Date of Birth Date Question Title * Proxy User Previous Names, if applicable Question Title * Proxy User Phone Number Question Title * Proxy User Email Address Question Title * Proxy User Address Question Title * Relationship to patient (select one)*Legal documentation required Parent Guardian/POA* Conservator* Other (please specify) Photo ID Upload Question Title * Requesting Party Photo ID Question Title * Permanent Guardianship of Adults, Power of Attorney, Conservatorship Authorization Question Title * PATIENT OR MINOR CHILD AUTHORIZATION FOR PROXY ACCESS:I understand that by signing below, proxy access is hereby granted to medical information through FHP Patient Portal for the above-named individual. I understand proxy access designation is voluntary and designating a proxy user is not required. I understand that proxy access may be revoked by submitting a written request at any time. I further understand Minor Patient Proxy Authorization access is limited and ends when a patient turns 18 years old.Typing my full name, date, and time in the boxes below serves as my signature and authorization to release my information.Signature of patient or legal representative: Requesting Party Signature Date Time Done
