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Patient Authorization for Proxy Access

Baptist defines a "proxy" as a person who I trust to act in my behalf to access my medical information. I UNDERSTAND AND ACKNOWLEDGE THAT BAPTIST ROUTINELY INCLUDES INFORMATION IN BAPTIST ONECARE MYCHART AND BAPTIST ONECARE MYCHART BEDSIDE ("MYCHART") RELATED TO DRUG AND ALCOHOL TESTING AND TREATMENT, THERAPEUTIC AND ELECTIVE ABORTIONS, SEXUAL HEALTH AND SEXUALLY TRANSMITTED DISEASES, GENETIC TESTING, MENTAL HEALTH CONDITIONS AND TREATMENT, DRUG SEEKING BEHAVIOR AND INSTANCES OF NON-COMPLIANCE. I FURTHER UNDERSTAND AND ACKNOWLEDGE THAT MY PROXY WILL MOST LIKELY BECOME AWARE OF ANY SUCH SENSITIVE INFORMATION BY BEING MY PROXY. I understand and acknowledge that to get my medical information regarding the foregoing, I will have to present in person at the Baptist facility that provided my care. Also, I understand and acknowledge that MyChart may contain information about my care and treatment at any clinic, practice, hospital or other facility regardless of whether the other entity is affiliated with Baptist.

I understand and acknowledge that allowing my Proxy to access MyChart is wholly voluntary and that I am not required to designate a Proxy or provide this authorization. I also understand and acknowledge that Baptist does not condition any of my health care treatment, payment or other services on whether I provide this authorization. However, I also understand and acknowledge that Baptist is prohibited by law from giving my Proxy access to my medical information without this authorization. I understand and acknowledge that I can always get a paper copy of my medical information.

I understand that once my medical information has been disclosed to my Proxy, it may be re-disclosed by my Proxy and the disclosed information will most likely not be covered by state or federal privacy protections.

I agree that this authorization will remain in effect until I OR Baptist cancels it. I UNDERSTAND THAT I CAN CANCEL THIS AUTHORIZATION AT ANY TIME BY FOLLOWING THE PROXY CANCELLATION INSTRUCTIONS ON THE MYCHART SITE OR BY PROVIDING A SIGNED, WRITTEN REQUEST TO BAPTIST AT THE FOLLOWING ADDRESS: BAPTIST ONECARE MYCHART, 350 NORTH HUMPHREYS BOULEVARD, MEMPHIS TENNESSEE 38120. However, I also agree that my cancelling this authorization shall not affect any releases of information made to my Proxy prior to my cancelling my Proxy's access.

I acknowledge and agree that neither Baptist nor any third parties affiliated or associated with Baptist provide any warranty or guarantee as to the accuracy, timeliness, performance, completeness or suitability of the information and materials found or offered on or through MyChart. I acknowledge that such information and materials may contain inaccuracies or errors and, to the fullest extent allowed by law, I hereby release Baptist and any third parties affiliated or associated with Baptist from any liability for such inaccuracies or errors. I agree to indemnify and hold harmless Baptist from any liability for such inaccuracies or errors. I agree to indemnify and hold harmless Baptist for any and all damages caused by the intentional or negligent acts or inactions of my Proxy.

I understand this information and I request and authorize my Proxy to access my medical information through MyChart as my designated and authorized Proxy.