Patient Forms
Welcome to MemorialCare Medical Group. For your convenience, please print and fill out all applicable forms and present them to the front desk when you arrive for your first office visit.
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myChart Proxy
| Proxy Type | Applies to | Proxy Form Required | Termination Process |
|---|---|---|---|
Pediatric | Allows a parent or guardian to have full access to myChart account of pediatric patient under the age of 12 | Yes. Access is obtained by completing the myChart Proxy Form and providing it to any MemorialCare front office staff. | Access automatically terms on the patient's 12th birthday. Another proxy form for Teen Proxy will need to be completed, or the teen may log into their myChart account and grant proxy access from the Sharing Hub. |
Teen | Allows a parent or guardian to have limited access to myChart account of pediatric patient between the ages of 12-17. | A patient can have their own myChart account at age 12. Once an account is created, proxy access can be granted through the Sharing Hub in the myChart menu or the myChart Proxy Form can be completed. | Access is automatically terminated on the child's 18th birthday. |
Teen (Enhanced) | Allows a parent or guardian to have full access to myChart account of pediatric patient between the ages of 12-17. | A patient can have their own myChart account at age 12. Once an account is created, proxy access can be granted through the Sharing Hub in the myChart menu or the myChart Proxy Form can be completed. | Access is automatically terminated on the child's 18th birthday. |
Adult | Allows an individual to have full access to the myChart account of an adult 18 years of age or older. | Proxy access can be granted through the Sharing Hub in the myChart menu or the myChart Proxy Form can be completed. | Access is terminated when the patient makes a written or online request to end access, a specified expiration date is reached, or the patient revokes access from within their own myChart account. |
Advance Health Care Directive
MemorialCare Medical Group/MemorialCare recommend completing an Advance Directive/Medical Power of Attorney/Living Will/Physician Order for Life-Sustaining Treatment (POLST) form on file in your medical record. See Palliative Care & Planning for more information.
MemorialCare Records
Use these forms to obtain your records from MemorialCare, or to have them sent to MemorialCare from another health provider.
- Authorization for Release of Medical Records - MCMG - English
- Authorization for Release of Medical Records - MCMG - Spanish
Opt-Out MemorialCare Health Information Exchange
Use this form to opt-out of the MemorialCare Health Information Exchange
If you have any questions or you need more information, please contact our Medical Records Department at (714) 665-1647 or by FAX at (714) 665-1644.