My Albemarle Medical Record Patient Forms

A proxy is a person who can access your information as if they were you. A spouse, adult child or caregiver may be granted full access to your medical records with proxy access. To authorize proxy access, please use the forms below. Once you have filled out the appropriate form, please bring it to hospital registration or medical records along with a photo ID. Proxy access will be granted within 24 hours.

Forms You May Need

Permission Slip - Teens (Ages 12-17)

As a parent/legal guardian, you can request that your teen ages 12-17 have access to their online medical record using this form.

Proxy Access Authorization Form - Teens (Ages 12-17)

A proxy is a person who can view patient information as if they were you. Use this form for teens ages 12-17 to gain proxy access to your teen's My Albemarle Medical Record account. Please Note: Requires that the teen child have their own My Albemarle Medical Record account activated to view.

Proxy Access Form - Adults and Children

A proxy is a person who can view patient information as if they were you. Use this form to grant a spouse, adult child or caregiver access to your medical records. You may also use this form to gain access to your child’s record if they are under the age of 12.

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