How do I initiate a proxy authorization?

To share your information or receive access to another person’s information, you must complete the appropriate proxy authorization forms which are available from any Ridgeview health care provider.

Self-authorization for ages 12 and above Use this form to receive access for minors ages 12 to 17 years. The minor will be required to sign the form allowing permission to access their information. 

Minor Patient Proxy Authorization Use this form to receive access for minors ages 0 to 11 years. Once the minor turns 12 years old a new proxy form will be required to be completed.

Autorización de representación de pacientes menores

Adult Patient Proxy Authorization Use this form to receive access for adults age 18 and above. Note: Access requests will be required to be renewed annually. 

Autorización de representación de pacientes adultos

Return form to Health Information Management Department:

E-mail: proxyform@ridgeviewmedical.org OR Fax: 952-442-6037
OR Mail to: Ridgeview, Attn: ROI, 500 S Maple St, Waconia, MN 55387