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Authorization to Release Behavioral Health

Authorization to release behavioral health information form.

Authorization to Release Information

This is the authorization form to release medical records and/or x-rays.

MyChart Adult Proxy

Fill out this form to give full access to your MyChart account information to another person.

MyChart Minor Proxy

Fill out this form if you are a minor who is granting access to your MyChart account to another person (parent, guardian, etc.).

MyChart Self-Authorization

Fill out this form to allow Lakewood Health System to release your personal health information for you to access via MyChart.

Patient Request for Health Information Form

Use this form to request access to your health information.

Patient Verbal Consent

Patients will no longer be signing an electronic consent when registering for their appointment. They will instead be asked to provide verbal consent to: (1) release their information for treatment, payment, and operations purposes; assign their benefits; contact their cellular phone; and acknowledge the Patient Bill of Rights and Notice of Privacy Practices information.

This verbal consent form provides the details of that consent.

Proxy Consent Form for Routine Care

Proxy Consent for Routine Care form allows Lakewood to provide routine medical care for patients.

Revocation of MyChart Proxy Access

Fill out this form to revoke someone’s proxy access to your MyChart account.