MyChart Adult Proxy Access Form - Swedish Hospital 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Clearly print the patient's name, date of birth, and social security number. Ensure that the street address, city, state, and zip code are accurately entered.
3. Read through the consent statements carefully. Acknowledge your understanding by checking the appropriate boxes regarding medical emergencies and personal health information.
4. In the 'Proxy’s Information' section, provide all required details for the adult requesting access. This includes their name, date of birth, social security number, address, phone number, and relationship to the patient.
5. Ensure both the patient and proxy sign and date the form in their respective sections to validate authorization.

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