En us pdf adult proxy form pdf you c 2026

1. Click ‘Get Form’ to open the en us pdf adult proxy form in the editor.
2. Begin by filling out the 'About the Patient/Member' section. Clearly print your name, date of birth, last four digits of your Social Security Number, email, phone number, and Member ID Number if applicable.
3. Next, complete the 'About the Proxy' section for the individual who will have access to your My Sanford Chart record. Ensure all fields are filled out clearly, including their name, date of birth, Social Security Number, email, address details, phone number, and Member ID Number if applicable.
4. Review the consent statements regarding what your Proxy can do on your behalf. Make sure you understand each point before proceeding.
5. Sign and date the form in the designated area. If required, ensure a notary public witnesses your signature.
6. Once completed and notarized (if necessary), send the form to Sanford Business Center at the provided address.

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