Sanfordchart org mychart en us pdf adult proxy form pdf 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'About the Patient' section. Clearly print the patient's name, date of birth, last four digits of their Social Security Number, email, and phone number.
3. Next, complete the 'About the Proxy' section for the individual who will have access to the patient’s My Sanford Chart record. Include their name, date of birth, last four digits of their Social Security Number, email, street address, city, state, zip code, and phone number.
4. Review the consent statement carefully. Ensure you understand what access you are granting your Proxy regarding your medical records and appointments.
5. Sign and date the form in the designated area. If mailing this form, ensure it is notarized before sending it to the provided address.

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