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Download Proxy Access Form - UnityPoint Health

Download Proxy Access Form - UnityPoint Health 2026

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The document is a request form for proxy access to a patient's health information through the MyUnityPoint patient website. It outlines the necessary information required from both the patient and the requestor, including personal details, relationship to the patient, and legal documentation if applicable. The form also specifies processing time, conditions for access, and includes sections for internal use by UnityPoint Health.

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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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Versions	Form popularity	Fillable & printable
2014	4 Satisfied (47 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How to get proxy access?

Setting up proxy access In most cases you will need to contact the GP surgery of the person who wants help, to ask for proxy access. The GP surgery will make sure the person giving access understands and agrees to it, where needed. You may both have to fill in a form and prove who you are using photo ID.

What is the first step when granting MyChart proxy access?

To give someone else proxy access to your account, please submit the request directly from your MyChart account. Go to Your Menu Share My Record. Under Who Can See My Record?, click Invite Someone. Follow the instructions to send an email invitation to the person who youd like to have access to your MyChart account.

What is proxy access to a patient portal?

Proxy access allows a person to use the patient portal to view another persons information. Patients may grant access to a designated individual, such as a spouse or medical decision caregiver.

How to give proxy access in MyChart?

Adult proxy Adults aged 18 and older can share their health information with another adult by doing the following: Log into your MyChart account. Go to the Menu and choose Sharing Hub. Select Manage Friend and Family Access. Both parties MUST have an active Prisma Health MyChart account.

How do you grant someone access to your MyChart?

Request Full Access to Another Adults MyChart Record The patient will go to Your Menu and choose Share My Record, click on Give friends and family access at the bottom of the page.

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What is the cost to use MyUnityPoint?

Cost. MyUnityPoint Alerts is a free service from UPH. However, message data rates may apply from your mobile carrier.

Download Proxy Access Form - UnityPoint Health 2026

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