EHR Consent Directive Request Form

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Please upload your completed EHR Consent Directive Request Form here: *

If you are submitting this request as a substitute decision-maker, please upload your proof of authority here:

If you are submitting this request as a substitute decision-maker, you must also submit one photocopy of a document that shows you are entitled to act as a substitute decision-maker for the individual identified in Section 1. For example, a legal document demonstrating you have sole custody or guardianship. Please refer to the instructions in the EHR Consent Directive Form for further information regarding the types of documentation that may be submitted as proof of authority.

* required

The file size must be less than 1.5 MB

Allowed file types: jpg, gif, png, doc, docx, pdf

Please provide an answer to the following addition question and then click “Submit” to successfully submit your form(s).