MR99119 Access to Another Adults MyChart Account 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Proxy’s information section. Enter the proxy's name, date of birth, address, last four digits of their Social Security Number, city/state/zip, telephone number, and email address.
3. Indicate whether the proxy has ever been a Cone Health patient by selecting 'Yes' or 'No'.
4. The proxy must sign and date the form to acknowledge understanding of the MyChart access terms.
5. Next, complete the Patient Information section with the patient's name, date of birth, address, last four digits of their Social Security Number, city/state/zip, telephone number, and email address.
6. The patient or authorized representative must sign and date this section to designate the proxy.
7. If applicable, have a physician complete the certification section if the patient cannot sign due to diminished capacity.
8. Review all entries for accuracy before submitting. Return completed forms via mail or email as instructed.

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