MyUofMHealth -

This form is used by adult patients to allow other adults access to their MyUofMHealth patient portal health information and other portal features by granting them proxy access. Your designated proxy is not required to be a patient at Michigan Medicine to sign up.

This form is intended for the patient’s use only. If you are not the patient click here to review proxy access request options.
Items marked with an asterisk are required for matching purposes.
You must provide the email address of the adult you are granting access to (it must be different from your email address).
We will communicate directly with you (the patient) regarding this request.

Your Medical Record Number or MRN is a 9-digit number that can be found on most of your Michigan Medicine paperwork or on your inpatient wristband. It is different from your billing account number and student ID. If you cannot locate your MRN, contact the HIE Support Help Desk at 734-615-0872 between 7:00 am – 7:00 pm, Monday through Friday or 8:00 am – 1:00 pm on Saturday.

Requirements

I understand granting proxy access to the MyUofMHealth Patient Portal account is voluntary.
I understand that adult patients (age 18 and older) can authorize another person to access their MyUofMHealth information to help with their health care needs. The person accessing my record is called a proxy. Proxy access can be stopped at any time by me (the patient) or the proxy.
I understand that even if I revoke proxy access, my proxy may have already viewed, saved, or downloaded my information.
I understand that my invited proxy will have 10 days to accept my invitation before it expires. If my proxy does not accept, I may need to send another request.
I understand my proxy will see the same medical information in the MyUofMHealth Patient Portal that I do.
I understand that full proxy access to MyUofMHealth may include information relating to the diagnosis and/or treatment of mental illness, alcohol/drug abuse, sexually transmitted infections (including HIV or AIDS test results), developmental disabilities and genetic testing results.
I understand that it is possible that the person receiving proxy access to MyUofMHealth records is not a health care provider or health plan covered by federal privacy regulations. The proxy could share or re-disclose my medical information without my permission, and it may not be protected by state or federal privacy laws

Patient's Last Name:

Patient's First Name:

Patient's Date of Birth(mm/dd/yyyy):

Patient Medical Record Number (xxxxxxxxx):

Patient's Country

Patient Street Address:

Patient's City:

Patient's State:

Patient's Zip Code(xxxxx):

Patient's Phone Number(xxx-xxx-xxxx):

Patient's Email Address:

Re-enter Patient's Email Address:

Proxy Relationship to Patient:

Proxy's Last Name:

Proxy's First Name:

Proxy's Date of Birth(mm/dd/yyyy):

Proxy's Country

Proxy's Street Address:

Proxy's City:

Proxy's State:

Proxy's Zip Code(xxxxx):

Proxy's Email Address:

Re-enter Proxy's Email Address:

Proxy's Phone Number(xxx-xxx-xxxx):

I hereby affirm that I am the patient identified above. I understand that I may be subject to penalties under law for submitting false or misleading information related to this application to grant access to my MyUofMHealth service.

I am at least 18 years old and am granting the following access to my health information to the above named adult.

Full/Limited Access:

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Adult Granting Access to Another Adult