Washington University Physicians

Washington University FollowMyHealth Patient Portal Adult Proxy Request Form

What is a proxy access for a health record?

Proxy access allows a guardian or other legally authorized adult to log into FollowMyHealth and connect to the account of a family member or another person. Proxy access is provided when the patient is unable to create their own portal account.

If you are a proxy for a patient over the age of 18, you will have access to their medical record, the ability to message providers and refill prescriptions.

What paperwork do I need to have?

In most instances, you will have to provide legal documentation to establish your right to act as the personal representative of the adult patient. Examples of legal documentation include legal guardianship and durable power of attorney for healthcare. These documents may be attached to this request or sent to:

Privacy Office
Washington University
Campus Box 8098
660 S. Euclid, 63110

or fax to 314-362-1199.

How long does it take?

For the protection of our patients, proxy accounts will only be granted to people who have the legal right to request medical information on behalf of our patient. Because this must be verified, proxy accounts may take longer to complete.

How do I sign up?

To request a proxy account, please fill in the boxes below and click Submit. You will receive an invitation to join through your Washington University FollowMyHealth account when the proxy account is ready.

Note: Boxes that require an entry are marked with an *.

About You

* First Name:
* Last Name:
* E-mail:
* Confirm E-mail:
* Mailing Address:
* City:
* State:
* ZIP/Postal Code:
* Telephone:  -  -  (###-###-####)
* Enter Invitation Code: This is provided by the clinic or on the portal brochure.

About the Patient

* First Name:
Middle Initial:
* Last Name:
* Date of Birth:  /   /  (mm/dd/yyyy)
* Sex:
* Soc. Sec. No.:  -  -  (###-##-####)
* Relationship to You:
* Legal Documentation:
Select File:
  If you are requesting a proxy account for a patient over the age of 18, please enter Yes if have legal documentation (i.e., Power of Attorney for Healthcare) stating you have responsibility for this person's healthcare. If there is no legal documentation, answer N/A or No. The patient will have to provide his/her written authorization and a photo ID with signature before a proxy account will be created. Please send copies of any documentation to the Washington University Privacy Office at Campus Box 8098, 660 S. Euclid Ave., St. Louis, MO, 63110 or fax to 314-362-1199.
* Provider:

This is the full name of the provider/location where the patient was informed about the Washington University Follow My Health patient portal.