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MyConsult Online Medical Second Opinion Consultation Proxy Form

MyConsult Online Medical Second Opinion Consultation Proxy Form


Please print and complete this form and send it to the Cleveland Clinic MyConsult office.

This form is to be used if you want the Cleveland Clinic to provide the online second opinion to an individual other than your physician.

The box or boxes below that apply must be checked and the form must be signed by the patient. In doing so, you are acknowledging: I am hereby consenting to the person below to act on my behalf and perform all of the actions listed:

Communicate with health care providers at the Web site and provide them with any and all information including medical records, films or test results that may be requested to use the services provided through this Web site.
Be consulted by and consult health care providers made available through this Web site on my behalf.
Receive any disclosures in any format related to my health or payment for services provided through this Web site.
Other.

A copy of the completed online medical second opinion report will be sent to the requestor of the consult.


I hereby acknowledge that I have given this consent of my own free will. This consent expires one year from the date signed. I can revoke this consent at any time (but not as to information that was released prior to the revocation) by contacting the Cleveland Clinic MyConsult office in writing.

Note: Up to two people can be named as Proxy to the requesting patient on one form.
 

_____________________________
Print Name of 1st Person to be named as Proxy
_____________________________
Relationship to Patient
_____________________________
Print Name of 2nd Person to be named as Proxy
_____________________________
Relationship to Patient
_____________________________
Print Name of Patient/Legal Guardian*
_____________________________
Signature of Patient / Legal Guardian*

Important: Two people, other than the Patient and designated Proxy must sign & date below acknowledging they witnessed the patient signing this form.

_____________________________
Witness
_____________________________
Date
_____________________________
Witness
_____________________________
Date

*Custodial parent or other person appointed pursuant to ORC §2111.01
Form must be printed and signed ink. E-signatures cannot be accepted

Please note: This form is valid for 365 days from the signature date.

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