Patient Portal Proxy Access Consent Form

Patient Portal Proxy Access Consent Form – Patient Age 18+

myCHP is an online portal that offers free access to medical information and allows you to conveniently connect with your health care team.

We understand that you wish to access UPMC Children’s Hospital of Pittsburgh online patient portal. Regarding this matter, privacy of the patient’s health care information is important to us. To obtain access, please review and complete the below request form. Expect a two-business day turnaround to receive the invitation. Please check your email account’s spam folder.

Enrollment for myCHP is available for proxies (representatives) of established patients age 18 years and older.

Do you already have an account? Login to myCHP to access your medical information.

For questions about your myCHP account, please contact our 24-hour, toll-free support line at 1-877-621-8014.

All fields are required.

Patient Name:
Patient Date of Birth:
Patient Sex:

PROXY ACCESS INFORMATION
By signing below, I agree to grant proxy access to the proxy designee listed on this form.

Patient Electronic Signature:

PROXY INFORMATION

Proxy Name:
Relationship to Patient:

Other:

Proxy Complete Email: Proxy Complete Email format is incorrect.
Proxy Date of Birth:
Proxy Phone Number:

By signing below, I acknowledge that I have read and understand the myCHP Terms and Agreement, and I agree to these terms.

Proxy Electronic Signature:

Agree to myCHP Terms and Agreement
myCHP Terms and Agreement

myCHP Terms and Agreement

I understand that myCHP is intended as a secure online source of confidential patient protected health information. If I share myCHP username and password with another person, that person will be able to view my health information.
I agree that it is my responsibility to select a confidential password, to maintain that password in a secure manner, and to change that password if I believe or know it may have been comproimised in any way.
I understand that myCHP contains select medical information from the patient's medical record and that myCHP does not reflect the complete contents of the medical record. I further undersand that myCHP contains information from Children's Hospital physician offices that use the Children's Hospital's electronic health record system, and that I will be able to access information from all of thse physician offices. Such information may be assocated with HIV, mental health, and drug and/or alcohol treatment.
I undersand that by gaining access, I will be permitted to do the following:

request appointments for healthcare services with Children's Hospital health care providers.
view the medical information that is availabe within myCHP
communicate with any of my Children's Hospital health care provdiers, via myCHP, regarding tests, treatments, medication, pateint advice, and administrative tasks
communicate, via myHCP, with UPMC's billing office regarding any UPMC bills

I understand that all activities within myCHP will be tracked by computer audit and that entries will become a permananet part of the medical record.
I understand that communication could be re-routed and not sent directly to the Provider. The messages will be reviewed and responded to or forawarded appropriately.
I understand that myCHP is not to be used in the event of medical emergencies. In the event of an emergency, I understand that I should either dial 9-1-1 or go to the closest hospital emergency room.
I understand that access to myCHP is provided by Children's Hospital as a convenience to its consumers. myCHP is not a subsititue of the full medical record. Children's Hospital has the right to deactivate access to my account at any time for any reason, including cases where Children's Hospital reasonably believes that it is not in the best interest to continue providing myCHP access to me.
I will not use myCHP access for purposes unrelated to the patient's care or treatment.
I understand that myCHP access is for the care of the patient. If I no longer want to have access, I should contact Children's Hospital by submitting the designated online form available on chp.edu/mychp. Expect a response within two business days.