MyBMGChart -

To request access to the record of a minor patient through MyBMGChart, please complete this form. Please note that the patient's chart will be accessed through your MyBMGChart account or an account created for you.

IS THE PROXY A CURRENT PATIENT OF BUFFALO MEDICAL GROUP?

YesNo

Your (Proxy) Information

All sections required. This section should be completed by the individual requesting access to another's MyBMGChart record.

First Name:

Last Name:

Middle Initial:

Date of Birth:

Street Address

City:

State:

Zip:

Phone Number:

Email:

SSN:

Patient's Information

All sections required. Complete this section with information about the patient whose MyBMGChart record you're requesting to access.

First Name:

Last Name:

Middle Initial:

Date of Birth:

Street Address:

City:

State:

Zip:

Phone Number:

MRN:

Relationship to Patient:

ParentGuardianHealth Care Proxy

MyBMGChart Terms and Conditions

I certify that I am the birth/adoptive parent or legal guardian of the individual listed above and that all information I have provided is correct.

The use of MyBMGChart is governed by the MyBMGChart Proxy Terms and Conditions of Use, a copy of which may be accessed when you sign in to your MyBMGChart account and whose terms are incorporated herein. By signature below, you agree to be bound by the MyBMGChart Proxy Terms and Conditions of Use. If, for any reason, you do not agree to be bound by the MyBMGChart Proxy Terms and Conditions of Use, MyBMGChart proxy access will immediately be terminated.

*Please note the following age range limitations for MyBMGChart. These age range limitations do not affect any legal right you have to access your child's record by other means. You may select both options to maintain access as your child ages.

Child Proxy Access Request (please check appropriate box(es):

Birth to 11 years of age: Parents and legal guardians are provided with full access to their child's MyBMGChart. A week before your child's 12th birthday, you will receive an email alerting you that your access will be transitioned to a limited proxy access (see below) the day before your child's birthday.12 to 17 Years of Age: Parents and legal guardians are provided with limited access to their child's MyChart (able to view your child's allergies and immunizations).

Receiving access to your child's chart begins once your child has an appointment and receives a MyBMGChart account. This is in keeping with privacy laws.

If, at any time after proxy access is granted, your relationship to the patient changes such that you no longer have the legal right to access his or her health information, you will immediately cease accessing any information regarding the patient in MyBMGChart and notify Medical Records at (716)-630-1213 of the change of circmstance.

I Agree

Relationship to Patient:

Date:

I certify that I have the legal right to this minor's medical information.

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This page was prepared for on Tuesday October 20, 2020 at 6:34:07 PM.

Request to Access a Minor's Record