Mykelseyonline 2025

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The document is an Adult Proxy/Release of Information Form from Kelsey-Seybold Clinic, allowing patients to authorize another adult to access their medical information through the MyKelseyOnline account. It outlines the necessary information required from both the patient and the proxy, emphasizes that participation is voluntary, and details the scope of information that may be shared, including sensitive health data. The form also explains the revocation process for this authorization.

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Click ‘Get Form’ to open the mykelseyonline document in the editor.
Begin by filling in your information in the 'Your Information' section. Ensure you print clearly and include your name, date of birth, email, address, and phone number.
Next, complete the 'Patient’s Information' section with the details of the patient whose MyKelseyOnline account you are requesting access to. This includes their name and date of birth.
In the designated area, write the name of the proxy who will receive access to the health information. Make sure to read and understand the authorization statement before signing.
Finally, sign and date the form at the bottom. If someone other than the patient is signing, indicate your authority and attach any necessary documentation.

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2014	4.5 Satisfied (45 Votes)

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