Download Proxy Access Form - UnityPoint Health: Fill out & sign online

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Click ‘Get Form’ to open the Download Proxy Access Form in our editor.
Begin by entering the Patient’s Name, including First, Middle Initial, and Last. This information is crucial for identifying the patient.
Fill in the Patient’s Date of Birth and Current Home Mailing Address, ensuring accuracy for proper processing.
Provide details about the Requestor, including their Name, Email, Contact Information, and Social Security Number. Specify your relationship to the patient from the options provided.
Indicate if there is a court or restraining order that limits access to the patient's health information by selecting 'Yes' or 'No'.
Select the type of request you are making regarding proxy access and ensure all required legal documentation is attached if necessary.
Complete the signature section by providing your Printed Name, Relationship to Patient, Signature, and Date. If using an electronic signature, confirm its validity as per legal requirements.

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