ProxyAccessRequesttomyccLink

PATIENT INFORMATION
PatientName:Date of Birth: MailingAddress: Phone Number: SSN: PatientEmail: SharedEmail: Yes No
PROXY REPRESENTATIVE INFORMATION
ProxyName:Dateof Birth: MailingAddress: _Phone Number: SSN: ProxyEmail: SharedEmail: Yes No
SIGNATURE(S) AND ACKNOWLEDGEMENT
Disclosure: ThisrequestonlyallowsProxyRepresentative to haveaccess to myhealthinformation via“myccLink”, includinginformation regardingHIV/AIDS, Drug/Alcoholuse,andMentalHealth, if present.
  • ProxyAccesswillautomaticallyexpireuponthe providedlegaldocument’sexpirationdate, oronce a minorreaches12 yearsof age, whichever comes first.
  • Imayrefuse tosignthisrequest. Myrefusalwillnotaffectmy abilityto obtaintreatment,payment, or eligibilityfor benefits.
  • I may inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of
  • I may revoke this request at any time, but I must do so in writing and submit it to the following address:
Contra Costa Regional Medical Center
Health Information Management Department
Attn: myccLink Proxy Access
2500 Alhambra Avenue
Martinez, CA 94553
Fax: (925) 370-5275
  • Myrevocationwilltake effectuponreceipt, excepttothe extentthatothershave actedinreliance uponthisrequest.
  • I have the righttoreceive a copyof thisrequest.
  • Bysigning thisrequest, I understandthatContraCosta RegionalMedicalCenter HealthCenters(CCRMC&HCs) willgive my ProxyRepresentative thesame access andprivilegesthat I havefor “myccLink”toviewportionsofmy protectedhealthinformation. I alsounderstandthatadditionalinformationmaybe available tomyproxyrepresentative throughthe patientportalas CCRMC&HCscontinuestoimplementthisproduct.
  • Informationdisclosedpursuanttothis requestcouldbe re-disclosedbythe ProxyRepresentative. Suchre-disclosureisinsomecasesnotprohibited byCaliforniaConfidentialityof MedicalInformationAct(CMIA)andmayno longer be protectedbyHealthInsurance Portabilityand AccountabilityAct of 1996(HIPAA). However, CMIAprohibitsthepersonreceivingmy healthinformationfrommaking further disclosureof itunlessauthorizationfor suchdisclosure isobtainedfrom meor unlesssuchdisclosure isspecificallyrequiredor permitted bylaw.

Patient Signature:_ Date:_

ProxyRepresentative Signature:_ Date:_

This formmust bedeliveredtoHealthInformationManagementDepartmentbythepatient orproxyrepresentative whowillneedtopresent a photo ID.

HIMDUSE ONLY: