Uvamychart 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient’s Name and Medical Record Number in the designated fields. Ensure accuracy for proper identification.
3. Fill in the Date of Birth and select the Gender option. This information is crucial for verifying patient identity.
4. Provide the Patient’s Address and email address, if applicable. If there is no email, check the corresponding box.
5. Next, enter details for the Adult seeking proxy access, including their Name, Phone number, Address, Date of Birth, and Email.
6. Indicate whether the adult proxy is a UVA Patient by providing their MRN or selecting 'Not UVA Patient'.
7. Specify the relationship to the patient by checking one of the options provided.
8. Both parties must read and sign where indicated to authorize access. Ensure all signatures are dated correctly.

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