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Proxy Access

When you sign-up for My Health Home, you can Manage family members' health records, once authorized.

Authorization can be granted by downloading a Proxy Access Request and Authorization Form and returning it to Campbell County Health Health and Information Services (Medical Records). The office is open Monday-Friday from 8 am-5 pm.

For more information about My Health Home, call 307-688-7878.

Download form


Need help completing the form?

If you would like to access your child's records, please follow these instructions:

Definitions

  • Patient – your minor child (under the age of 18)
  • Parent – legal parent or permanent legal guardian
  1. Under the Minor Child section, mark either Parent or Permanent Legal Guardian
  2. Select Age Group
  3. Provide the Parent or Permanent Legal Guardian Signature on the last page
  4. Parent or Permanent Legal Guardian also signs for the patient who is minor under the age of 18.
  5. The signatures must be witnessed by someone over the age of 18.

If you would like to access your spouse or parent's records, please follow these instructions:

Definitions

  • Proxy – Individual (over the age of 18) identified by the patient who is approved by the patient to access the patient's medical records.
  • Patient –Individual (over the age of 18) receiving care
  1. Under the Adult Patient section, mark Adult Capable, Adult Patient or Legal Guardian of Adult Patient.
  2. If you mark Legal Guardian of Adult Patient, you must provide legal documentation to the Medical Records Staff stating legal guardianship has been granted.
  3. Patient and Proxy sign the last page.
  4. The signatures must be witnessed by someone over the age of 18 and the witness may not be the patient or proxy.

For more information about My Health Home, call 307-688-7878.