I have read and understand the requirements and procedures regarding proxy access above. All informatoin I have provided is correct. I understand that:
The undersigned grants proxy access to his/her Baptist Health MyChart record to the person requesting proxy access listed above. Or, for a minor patient or incompetent patient, the undersigned grants proxy access to the patient's Baptist Health MyChart record on behalf of the patient to the person requesting proxy access listed above. This form must be signed by the patient if a competent adult or minor over 13 years of age.