Adult
Advocate Medical Group MyAdvocate Proxy Consent Form
This form must be completed by the patient or legal guardian to provide access by a Proxy to the on-line
medical records of an Advocate patient. Each individual requesting access must have a MyAdvocate
account. A new MyAdvocate account will be established for those that do not currently have one.
TERMS and CONDITIONS OF USE:
The Proxy must agree to the following:
1. I must log into MyAdvocate with my own user ID and password.
2. I will abide by the terms and conditions of the MyAdvocate site.
3. My access could be terminated with a written request by the patient.
4. Advocate Medical Group has the right to revoke on-line access at any time.
I also understand that:
1. For medical emergencies, dial 911. MyAdvocate is NOT to be used for urgent needs.
2. All communication on behalf of this patient must be sent from the MyAdvocate Proxy account
and responses will be received in the MyAdvocate Proxy account.
3. All communication is sent to the nursing staff in the department, not directly to the Provider. The
messages will be reviewed and responded to or forwarded appropriately.
4. I will receive a MyAdvocate activation letter notifying me when access is available. This is
normally sent within 5 – 7 business days after the consent form is received by the Advocate
Medical Group Medical Records department.
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Please enter YOUR information:
Relationship to Patient: ______________________
Name: __________________________________
Medical Record #: ______________________
Former Name(s) - e.g. maiden name:___________________________________________________
Address: _______________________________
Date of Birth: _________________________
_______________________________________
Social Security #: _______-_______-_______
Telephone Number: _________________________________________
Do you have an active MyAdvocate account? ___Yes ____ No ___ Don’t Know
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Note: Access to the patient’s online record is only available to family member with patient consent
or legal guardians.
Please enter the Patient’s information:
1. Patient Name: ___________________________ Medical Record #: _______________________
Former Name(s):_________________________________________________________________
Current Address: ________________________________
________________________________________
Date of Birth: ___________________
Social Security #: _______-_______-________
-------------------------------------------------------------------------------------------------------------------------2. Patient Name: ___________________________ Medical Record #: ________________________
Former Name(s):_________________________________________________________________
Current Address: ________________________________
________________________________________
Date of Birth: ____________________
Social Security #: _______-_______-________
-------------------------------------------------------------------------------------------------------------------------*************************************************************************************
By signing below, I acknowledge that I have received a copy of this form and I accept the MyAdvocate Terms and
Conditions of Use. I also understand that this Authorization is subject to revocation/withdrawal by me at any time
in writing to the medical record contact person at this site of care except to the extent the action has already been
taken to release this information. An effective written revocation will also disqualify me from further access to and
use of MyAdvocate. I also agree to hold Advocate Medical Group harmless and indemnify Advocate Medical
Group for any damages, liability, debts, fines or attorney’s fees that Advocate Medical Group may incur as a result
of my failure to abide by the Advocate Medical Group MyAdvocate Terms and Conditions of Use. Advocate
Medical Group will not condition treatment on my signing this authorization. I also understand that once
information is released pursuant to this authorization, Advocate Medical Group cannot prevent the re-disclosure of
the information to another third party.
Signature of Family Member/Legal Guardian/Personal Representative
Patient signature
Date