Proxy Access

Giving Family Members or Caregivers Proxy Access

No one person is automatically granted access to another person’s information except parents of children under 9 years of age. Proxy access allows you to give your designee (family member, power of attorney) access to your personal and protected health information via the online patient portal MyHEALTH. By giving someone else proxy access to your patient portal, they will see all the information available on MyHEALTH that you do, including HIV/ADIS, mental health and or drug and alcohol abuse and treatment information about you.

You can give family members, and others, including powers of attorney, access to your Portal. To do so, please access the Proxy Consent Form (Click here). As the patient requesting to give proxy access to your designee you must:

  1. Bring the signed form to the Health Information Management Department with your valid photo identification. The CHH HIM office is located on the first floor of the hospital’s main building. The office is open Monday through Friday, 8:00 AM – 4:30 PM.
  2. Patient or Proxy without patient (if Proxy has POA or HealthCare Agent paperwork) can faxed or mailed if notarized to the HIM department at:

    Health Information Management Department
    Charlotte Hungerford Hospital
    540 Litchfield Street
    Torrington, CT 06790
    Attn: Privacy Officer
    Phone: 860.496.6672
    Fax Number: 860.496.6629

This proxy form will be scanned into and kept as a part of your permanent medical record until revoked, in writing by you. All proxy consents expire with the patient.

Proxy access only ends when you revoke the consent for the access. Your request must be made in writing, using the hospital approved Authorization for Cancellation or Revocation of Proxy Access Form, (Click here).

Fax or mail the signed form to the HIM department at:

  • Health Information Management Department
    Charlotte Hungerford Hospital
    540 Litchfield Street
    Torrington, CT 06790
    ATTN: Privacy Officer
    Phone: 860.496.6672
    Fax Number: 860.496.6629

Charlotte Hungerford Hospital