Name: | DOB: | MRN: | PCP:

Adult Granting Access to Another Adult

Use this form if you are an adult patient (18 years or older) and wish to allow another adult access (grant proxy) to your account.

Before granting proxy to your account, understand:

  • The patient and the proxy must both have email addresses.
  • The patient may allow Full or Limited access to the account.
    •        Full access may include information relating to the diagnosis and/or treatment of mental illness, alcohol/drug abuse, sexually transmitted infections (including HIV or AIDS test results), developmental disabilities and genetic testing results.
  • The patient has the right to revoke access to the proxy at any time. It is the patient’s responsibility to revoke proxy access by deactivating the proxy account.
  • Authorizing "proxy" to the adult name on this form is not covered under HIPAA and is not subject to federal health information privacy laws. A proxy could further disclose health information and it may no longer be protected by federal law.

Medical Record Number (MRN): Each patient has a unique Medical Record Number. Your medical record number must be entered using 9 digits. If your medical record number is less than 9 digits, add zeros to the beginning of your number. Example: 123456 must be entered as 000123456. You may locate your MRN on your blue registration card (listed as CPI number) or your Summary of Care note given to you following your appointment. The medical record number is listed as MRN# in the upper left corner on the Summary of Care document. You can also find your medical record number on label stickers on most medical information from your doctor. Your MRN is NOT the same as the account number that appears on your billing statements. If you cannot locate your MRN, contact Patient Portal Support at 734-615-0872 between 7:00 am - 7:00 pm, Monday through Friday or 8:00am - 1:00pm, on Saturday.