University Hospitals Terms and Conditions Of Use – Proxy

I understand it is my choice to use MyChart and my choice to authorize another individual or individuals to access my personal health information as a “proxy”. By submitting this request, I authorize the individual designated by me in this request (my “Proxy”) to act on my behalf regarding any and all of my health information contained in my University Hospitals MyChart, which shall include, but not be limited to, receiving access to MyChart functions which allow my Proxy to view, download, and/or transmit to third parties any and all of my health information, according to the MyChart Terms and Conditions. I further authorize University Hospitals to disclose via MyChart any and all of my health information contained in my University Hospitals MyChart to my Proxy for any purpose that my Proxy deems to be appropriate. I understand and acknowledge that this authorization may include treatment for physical and mental illness, alcohol and/or drug abuse, and/or AIDS (Acquired Immunodeficiency Syndrome), and/or may include results of an HIV test or the fact that an HIV test was performed.

After my health information is released, my information may be re-disclosed by the recipient and may no longer be protected by law. I understand that this request is entirely voluntary and treatment, payment, enrollment, or eligibility for benefits will not be based on whether or not I submit and sign this authorization.

I acknowledge that I can stop or change access to my Proxy at any time. I can stop, revoke, or change access through MyChart. In addition, I acknowledge that this authorization for my Proxy’s access to my University Hospitals MyChart will automatically expire for a parent or legal guardian when a minor turns 18 or when I deactivate my University Hospitals MyChart account. Any revocation will not apply to information that has already been disclosed in response to this authorization.

I may choose to use other services provided by third parties in conjunction with my use of MyChart. Such services may include, but are not limited to, translation services, location services, and other third-party offerings. Any links to such services are provided for your convenience only. Neither Epic nor University Hospitals have control over the contents of these services, and neither Epic nor University Hospitals accept any responsibility for them or for any loss or damage that may arise from your use of them. Such services may require me to submit my information to a third party, which may result in a copy of my information being used and/or stored by a third party. If I decide to access any such services in conjunction with my use of MyChart, I do so entirely at my own risk and subject to the terms and conditions of use for such services.