Patient Forms

Welcome to MemorialCare Medical Group. For your convenience, please print and fill out all applicable forms and present them to the front desk when you arrive for your first office visit.

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myChart Proxy Access

Proxy access allows

parents, legal guardians and caregivers to log into their personal myChart accounts, and then connect to medical information for the patient they represent. Available access is based on age of the patient and proper authorization.

With Partial Access, proxies can:

See most of what patient can view, excluding information related to sensitive topics and communicate with the doctor’s office.
Proxies do not have the ability to:
Request prescription refills or view appointments.

With Full Access

proxies can enjoy the same features and benefits available to the patient including access test results, Communicate with the doctor’s office, manage appointments and request prescription refills.

Patients 11 & under

Partial proxy access

does not apply to this age group.

Full proxy access

is available to parents and legal guardians

Patients 12 - 17

By default

proxy access is limited to help protect the privacy of our patients. Access changes begin on the patient’s 12th birthday.

Full access is available

With the agreement of the patient’s trusted care provider and patient authorization, full access is available. Proxy access is reassessed annually and ends on the patient’s 18 birthday.

Patients 18 & over

Partial proxy access

does not apply to this age group

Adult-to-adult proxy access

is available with authorization from the patient

Advance Health Care Directive

MemorialCare Medical Group/MemorialCare recommend completing an Advance Directive/Medical Power of Attorney/Living Will/Physician Order for Life-Sustaining Treatment (POLST) form on file in your medical record. See Palliative Care & Planning for more information.

Use these forms to obtain your records from MemorialCare, or to have them sent to MemorialCare from another health provider.

Use this form to opt-out of the MemorialCare Health Information Exchange

If you have any questions or you need more information, please contact our Medical Records Department at (714) 665-1647 or by FAX at (714) 665-1644.