AveraChart Proxy Access

Do you need access to your child's or parent's record?

AveraChart lets you view your child's or another adult's health information and you can give another adult access to your AveraChart account. Child age restrictions apply.

Please download the proxy form, complete and return to your clinic or fax to 605-504-9701. Records for children 12 years old or older cannot be accessed without a completed proxy form.

• Proxy Form English
• Proxy Form Spanish

You have a right to revoke or remove an authorization for access to your AveraChart. Please complete and sign this form to revoke or cancel an authorization.