Everett Clinic Mychart Activation Details

Form Con 160, submitted by the taxpayer and signed under penalty of perjury, is used to claim a refund or credit on an income tax return. The form is divided into four parts: Income, Adjustments, Deductions, and Credits. Each part lists specific information about the taxpayer's income, adjustments, deductions, and any credits that may be claimed. The form must be accompanied by a schedule supporting the information reported on Form Con 160. Taxpayers who file their returns using Form Con 160 should ensure that all of the information on the form is accurate and complete. Any mistakes can result in delays in processing the return or even a rejection of the return altogether.

You'll find more information in regards to the form con 160 by checking out the listing we prepared.

QuestionAnswer
Form NameForm Con 160
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmycharteverettclinic, mychart everett clinic my chart, mychart everett clinic, my chart the everett clinic

Form Preview Example

Not activated as of __________

Child Proxy Form

MYChart

Child Proxy Form

Access to Your Child’s MyChart Account:

(Medical Record)

PATIENT LABEL HERE

OR

Patient Name____________________

Date of Birth_____________________

MRN____________________________

@CON-160@

To sign up for access to your child’s MyChart, please complete and sign this Child Proxy Form and return it to the address shown below. If you are an Everett Clinic patient you will need to have an active MyChart account in order to access your child’s MyChart. If you are not a patient at The Everett Clinic, we will set up an account for you once this form has been processed.

Return all forms to: The Everett Clinic or Fax: (425) 339-5439 Medical Records – Release of Information 3901 Hoyt Avenue

Everett, WA 98201

Parent/Guardian Information: (Completion of all sections is required -- please print clearly)

Name (last, first, middle initial): __________________________________________________________

Date of Birth: ____________________

Street Address: _______________________City: ___________State:_____________ Zip:___________

E-mail Address: ____________________________ Phone Number: ____________________________

Please note the following age range limitations for MyChart. These age range limitations do not affect any

legal right you have to access your child’s record by other means. To request a copy of your child’s record in paper or electronic format, contact the Health Information (Medical Record) Department at The Everett Clinic.

If your child is age 0-12: You will be granted access to your child’s MyChart.

Once your child reaches age 13, you will have limited access to your child’s MyChart (see below).

The following information is needed for proxy access: (All fields are required. A form must be provided for each child.

If you need additional forms, request another proxy access form from the Health Information (Medical Record) Department or print one from www.everettclinic.com/MyChart).

Name (last, first, middle initial): __________________________________________________________________

Date of Birth: ________________________

MyChart Terms and Agreement

I understand that MyChart is intended as a secure online portal for viewing confidential medical information.

If I share MyChart ID and password with another person, that person may be able to view my or my child’s health information, and health information about someone who has authorized me as a MyChart proxy.

I agree that it is my responsibility to select a confidential password, to maintain my password in a secure manner, and to change my password if I believe it may have been compromised in any way. I understand that MyChart contains selected, limited medical information from a patient’s medical record and that MyChart does not reflect the complete contents of the medical record. I also understand that a copy of a patient’s medical record may be requested from The Everett Clinic.

This form only authorizes access through MyChart and does not authorize release of medical records by other methods or in other formats.

I understand that once information has been disclosed, it potentially may be re-disclosed and the disclosed information may not be covered by federal privacy protections.

I am aware that The Everett Clinic does not condition any health care treatment, payment, or other services on signing this authorization.

CON-160 11/11 (CONSENT)

Child Proxy Form (page 2)

I understand that patients age 13 and above must consent for the release of information for treatment of mental health and/or substance abuse and patients age 14 and above must consent for the release of information of treatment for birth control and/or sexually transmitted diseases. I understand that my activities within MyChart may be tracked by computer audit and entries I make may become part of the medical record.

I understand that access to MyChart is provided by The Everett Clinic as a convenience to its patients and that The Everett Clinic has the right to deactivate access to MyChart at any time for any reason. I understand that use of MyChart is voluntary and I am not required to use MyChart or to authorize a MyChart proxy.

By signing below, I acknowledge that I have read and understand this MyChart Sign-Up form and I agree to its terms.

This proxy authorization will expire in 90 days if the associated MyChart account is not activated within that time period.

______________________________________________/___________________________/____________________

Signature of Parent/Guardian Relationship to Patient Date (Required)

This form will be scanned into the patient’s chart

CON-160 8/11 (CONSENT)

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