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

MyChart sign-up authorization for ages 12-17. Use this form for minor patients ages 12 to 17 years old to authorize Ridgeview to create a MyChart account on their behalf.

If you would like to grant proxy access to a parent, guardian or other support person, please sign and submit the form below.

Minor Patient Proxy Authorization. Use this form to receive proxy access for:

• Minor ages 0-11 years old for full proxy access
• Minor ages 12-17 years old for limited proxy access (minor's signature not required)
• Minor ages 12-17 for full proxy access (minor's signature required)

Autorización de representación de pacientes menores

Adult Patient Proxy Authorization Use this form to receive access for adults age 18 and above.

Autorización de representación de pacientes adultos

Note: Access requests will be required to be renewed every five years.

Return form to Health Information Management department via email, fax or mail: