PatientLink Request form
Are you a parent or guardian requesting access to another persons records?
Yes
No
Please visit the
proxy account access page
and complete the appropriate request form. After you complete the form and submit appropriate documentation you will be on your way to receiving proxy access for the patient’s health information.
First Name
Last Name
Email address (Patients email address)
Confirm email address
Date of birth (mm/dd/yyyy)
Patient age
What are the last 4 digits of your SSN?
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Contact Information
