Proxy Access and Authorization Form

Patient Label

Please return the completed form to the patient’s physician office or primary care doctor, or the Health

Information Management Department. Completed forms should be scanned into the patient’s medical

record and proxy access established once identity has been verified.

Access to a Child, Teen, or Adult

Cedars-Sinai, My CS-Link Record

This form should be completed by a parent or permanent legal guardian (“Proxy”) who

wants to request access to another patient’s (or your child’s) My CS-Link Record. The

Proxy will need to show a photo ID and/or relevant legal or court documents asserting

their right to make such request.

Please complete all pages of this Proxy Access and Authorization Form. Access to the

child, teen or adult’s My CS- Link Record will be through your My CS-Link Account.

Select one (1) from the following Proxy Access options and follow the instructions with

that section(s).

☐ Child Proxy- If the patient is a minor between the ages of 0-11, Proxy will be

granted full access to the minor patient’s My CS-Link Record until the child

reaches age 12. The day before the 12

birthday of the patient, all proxy access

is automatically switched to no access. Complete sections 1, 2, and 3 of this

form.

☐ Teen Proxy- If the patient is a minor between the ages of 12-17, Proxy access is

limited to ensure privacy for our patients in accordance with the California

Confidentiality of Medical Information Act (CMIA) State Laws around adolescent

confidentiality rights. For example, Proxy will not have access to certain aspects

like teen’s medical notes or test results, but can view teen’s upcoming visits with

all providers and message providers on behalf of teen. The day before the 18

birthday of the patient, all proxy access is automatically revoked and new proxy

access must be pursued to re-establish proxy access, if the patient desires.

Complete sections 1, 2, 3, and 4 of this form.

☐ Adult Proxy and Proxy Access for Minor Patient with Legal Authority to

Consent - If the patient is an adult (18 or older) OR minor patient is

emancipated, married, self-sufficient, on active duty with Armed Forces, or

otherwise has legal authority to consent for self, consent from the patient or

permanent legal guardian is required for Proxy access to the patient’s full My CS-

Link record. Complete sections 1 and 4 for this form.

☐ Proxy Access for Patients Without Decision-Making Capacity- Consent from

the permanent legal guardian is required to access the patient’s My CS-Link

record. Complete sections 1, 2, and 3 for this form. The patient's physician

should complete the Physician Certification section of this form.

Patient Label

Please return the completed form to the patient’s physician office or primary care doctor, or the Health

Information Management Department. Completed forms should be scanned into the patient’s medical

record and proxy access established once identity has been verified.

Section 1: Parent/Permanent Legal Guardian (“Proxy”) Information

In order to view the patient’s information, the Proxy must also obtain their own My CS-

Link account.

Proxy’s Name: __________________________ DOB: _______________________

Last Four SS#: __________________________ Phone: _______________________

Street Address: _________________________________________________________

City: _________________________ State: ___________ Zip: ___________________

Relationship to Patient: _______________________

Note: Legal documents may be required, e.g. power of attorney for healthcare, court

order, etc.

Section 2: Patient’s Name: (Please print clearly)

If you have more than one patient for whom you would like proxy access, please print

and complete another form.

Patient’s Name: ____________________________ DOB: __________________

Medical Record Number (if known): _____________ Phone: __________________

Street Address: _________________________________________________________

City: ________________________State: ___________ Zip: _____________________

Section 3: User Acknowledgment of Terms and Conditions for Use of Cedars-

Sinai My CS-Link Record.

By signing below, I acknowledge and agree that as the Proxy:

1. I will be using my own My CS-Link account to access the patient’s, for whom I

am requesting proxy access, My CS-Link account.

Patient Label

Please return the completed form to the patient’s physician office or primary care doctor, or the Health

Information Management Department. Completed forms should be scanned into the patient’s medical

record and proxy access established once identity has been verified.

2. I will comply with the terms and conditions on the My CS-Link web page (located

at https://patients.mycslink.org, then select the Terms and Conditions link on the

page) and this document.

3. I will keep my password confidential and not share this information with anyone.

4. I must have parental rights or permanent legal guardianship rights or the patient’s

consent to access this patient’s record.

5. I have not been denied periods of physical placement with the patient and there

are no court orders or restraining orders in effect limiting my access to this

patient’s medical records and/or information.

6. Communications on behalf of the patient through My CS-Link must be sent from

the patient’s record and responses will be received in the patient’s record.

7. There are age range limitations for My CS-Link. These age range limitations do

not affect any legal right I have to access the patient’s record by other means.

Furthermore, I understand that Cedars-Sinai My CS-Link Chart does not reflect

the complete contents of the medical record, and I can request a paper copy of

the patient’s record by contacting the Health Information Department at 310-423-

2259.

8. For a patient age 0 to 11 years, I will be granted full access to the patient’s My

CS-Link record. On the patient’s 12th birthday, I will no longer have access to

the patient’s My CS-Link record.

9. For a patient 12-17 years, I will be granted limited access due to California State

confidentiality laws specific to teen patients. On the patient’s 18

birthday, I will

no longer have access to the patient’s My CS-Link record.

10. I authorize the Use or Disclosure of Electronic Protected Health Information.

11. I understand that access to Cedars-Sinai My-CS Link Record is provided by

Cedars-Sinai as a convenience to its patients and that Cedars- Sinai has the

right to deactivate access to My CS--Link Record at any time for any reason. I

understand that the use of My CS-Link Record is voluntary and that I am not

required to use Cedars-Sinai or to authorize My CS Link proxy. Cedars-Sinai

reserves the right to revoke online access to My CS-Link at any time.

12. I understand that in some cases lab/test results will be released without prior

provider review or without prior consultation between patient and the health care

provider.

13. If my legal status changes, I will notify Cedars-Sinai Health Information

Department at 310-423-2259.

X___________________________/______________________ /__________________

Proxy Signature Proxy Name-Printed Date

Patient Label

Please return the completed form to the patient’s physician office or primary care doctor, or the Health

Information Management Department. Completed forms should be scanned into the patient’s medical

record and proxy access established once identity has been verified.

Section 4: This section is an authorization that will allow Cedars-Sinai to release

your health information to your designated adult proxy. This form should be

completed by the patient who is authorizing another person to access the health

information in his or her My CS-Link Record.

Patient Name: _____________________________ DOB: ____________________

Last Four of SS#: __________________________ Phone: ____________________

Street Address: _________________________________________________________

City: _________________________ State: ___________ Zip: ___________________

I hereby authorize Cedars-Sinai to grant access to all my health information in My CS

Link Record. This may include sensitive information.

Proxy Representative __________________________ DOB: __________________

Last Four of SS#: _____________________________ Phone: _________________

Street Address: _________________________________________________________

City: _________________________ State: ___________ Zip: __________________

Relationship to me: _______________________

Notice/Restriction: California law prohibits the Proxy Representative from making

further disclosure of your health information unless the recipient obtains another

authorization from you or unless the disclosure is permitted by law. This protection may

not extend to recipients outside the state of California. This authorization does NOT

allow my Proxy Representative to (1) make health care decisions of my behalf OR (2)

access my health information other than via My CS-Link online.

Your rights/Expiration of Authorization:

As the patient/patient representative, you have the right to request a copy of this

authorization.

Unless otherwise revoked, the authorization for My CS Link Record Access shall be

valid for 5 years or until terminated by the patient or Proxy electronically or in writing. I

Patient Label

Please return the completed form to the patient’s physician office or primary care doctor, or the Health

Information Management Department. Completed forms should be scanned into the patient’s medical

record and proxy access established once identity has been verified.

may refuse to sign the authorization at any time electronically or in writing. If written, the

revocation must be signed by me or in my behalf and sent to the Health Information

Management Department via mail, fax, or email.

Mail to: Cedars Sinai Medical Center, Health Information Management Department,

8700 Beverly Blvd., Room 2901, Los Angeles, CA 90048

Fax:310-423-0113

Email: [email protected]

The revocation is effective upon receipt but will have no impact on uses or disclosures

made while the authorization was valid.

By signing below, I authorize the My CS-Link access disclosure and I read, understand

and agree to the My CS-Link Terms and Conditions.

Patient Signature: ________________________

Date: ________________________

For Official Use:

1. I have given a photocopy of the signed My CS-Link Authorization document to the

patient.

2. I have viewed the Proxy’s government-issued ID on _________________by

Signature of Cedars-Sinai Staff _______________________

Printed Name of Cedars-Sinai Staff _______________________

Patient Name: ______________________ Patient DOB: ______________

Patient MRN (optional): _______________

Patient Label

Please return the completed form to the patient’s physician office or primary care doctor, or the Health

Information Management Department. Completed forms should be scanned into the patient’s medical

record and proxy access established once identity has been verified.

Physician Certification

Based on information provided to me**, I have determined that it is appropriate for the

Proxy to have access to the patient’s My CS-Link account for purposes relevant to the

Proxy’s role as a caregiver of the patient. This information may include a health care

directive previously signed by the patient/legal guardian or other information available to

me, together with my determination of the patient’s lack of medical decision-making

capacity.

X______________________/______________________/_____________/__________

Physician Signature Physician Name (printed) Date Time

** Comments on Physician Certification

There are a variety of circumstances in which an adult would be making decisions for a

patient who lacks medical decision-making capacity. The physician will need to

determine whether it is proper for an adult to be given proxy access to a patient’s My

CS-Link account if the patient lacks the capacity to provide authorization for the access.

The following are observations for guidance.

1. If the patient, at a time when he or she had decision-making capacity, completed a

form of legal authorization to make health care decisions for the patient such as an

advanced health care directive or health care power of attorney, the agent (“Agent”)

named in that document may be given proxy access if the patient has lost decision-

making capacity. (Be sure to review the document to confirm the authority given).

2. Often the agent does not live near the patient and the agent has delegated day-to-

day caregiving responsibility to a local caregiver. In such cases, the agent would need

to authorize the release of health information to the local caregiver using authorization

forms compliant with federal and California law. Forms are available at www.cedars-

sinai.edu/medicalrecords. For patients of Cedars-Sinai Medical Group, please visit

www.cedars-sinai.edu/medicalgroupnewpatientinfo. Upon receipt of the authorization,

the physician should be comfortable giving proxy access.

3. If the physician has an established relationship with the patient, has determined the

patient lacks decision-making capacity, and the same caregiver is the clinical decision-

maker, it may be appropriate for the physician to approve proxy access for that

caregiver.

4. If the patient’s capacity to make clinical decisions returns, this proxy access should

be terminated.