Name: | Legal Name: | DOB: | MRN: | PCP:

MyUofMHealth Parent/Guardian/DPOA Proxy Access Request Form

Proxy access allows parents and legal guardians to gain access to health information for their child(ren) and adults they are responsible for by connecting their personal MyUofMHealth portal to the child or adult they represent.

  • Additional supporting documentation may be required. For more information on the type of documentation required for legal guardians and Durable Power of Attorney for Health Care visit our FAQ.

If you have questions about this form or are unable to locate the patient’s Medical Record Number, contact the HIE Support Help Desk at 734-615-0872 between 7:00 am – 7:00 pm, Monday through Friday or 8:00 am – 1:00 pm on Saturday.

Requirements

You must be the parent or legal guardian of the patient to use this form. Supporting documentation may be required.

For Minor Patients

Please note there are limitations to your proxy access in MyUofMHealth based on the patient’s age. These limitations do not affect any legal right you have to access your child’s health record. For more information about partial access visit our FAQ or click here to learn more about requesting medical records.


  • Age 0-10: Full access to MyUofMHealth features.

  • Age 11-17: Partial access to MyUofMHealth features.

  • Age 18 or older: Parental access expires, additional legal documentation or authorization from the patient is required.