Name: | DOB: | MRN: | PCP:

Authorization for Health Care Power of Attorney or Legal Guardian to Access Health Information in My UNC Chart

This form may only be completed by an individual ("Legal Proxy") who has the valid legal documents to act:

  • • as a Health Care Power of Attorney or Permanent Legal Guardian for the patient identified below (“Patient”), who is: (1) 18 years or older; and (2) cannot make and communicate his/her health care decisions or has been declared incompetent by a court with jurisdiction over Patient; or
  • • a Permanent Legal Guardian for Patient who is: (1) an emancipated minor; and (2) has been declared incompetent by a court with jurisdiction over Patient.

The Legal Proxy should complete this form if the Legal Proxy wants access to portions of the patient’s electronic protected health information maintained through My UNC Chart. Since the patient cannot make and communicate his/her health care decisions, the patient will not have his/her own My UNC Chart account.

Patient's Information:

Legal Proxy Information:

(The person who will have access to the patient's health information in My UNC Chart)

Legal Proxy's Relationship to Patient is as follows:


Health Care Power of Attorney -Legal Proxy must attach copies of: 1) the valid Health Care Power of Attorney; and 2) the Physician Certification verifying Patient lacks decisional capacity. NOTE: This option is not available in the case of an incompetent emancipated minor patient.**

Permanent Legal Guardian -Legal Proxy must attach copies of: 1) the court order appointing the Legal Proxy as Patient’s Permanent Legal Guardian; and 2) Letters of Guardianship verifying the Legal Proxy’s status as Patient’s Permanent Legal Guardian. NOTE: This is required for an incompetent emancipated minor patient.**

Acknowledgment:


By checking the box below, I acknowledge and agree that:

•I will be using my My UNC Chart Legal Proxy account to access Patient’s electronic protected health information.
•I will comply with the My UNC Chart’s Terms and Conditions.
•I have valid legal documentation authorizing me to act on behalf of Patient, thereby allowing me to access Patient’s electronic protected health information.
•I have provided a picture ID.
•When my legal authority to act on behalf of the patient has been inactivated, revoked, terminated or expired, I will immediately notify UNC Health Care in writing of the inactivation, revocation, termination or expiration and mail it to: UNC Health Care – Eastowne Campus, Health Information Management, Building 500 Eastowne Drive, Chapel Hill, NC, 27514.
•This Authorization will expire once my legal authority to act on behalf of the patient has been inactivated, revoked, terminated or expired or once I revoke this Authorization, and I will immediately cease accessing Patient’s electronic protected health information via My UNC Chart upon expiration of this Authorization.

Enter your first and last name in the boxes below to serve as your electronic signature.