FMH Proxy Request

FMH Proxy RequestVisalia Medical Clinic




What is a Proxy?In the context of a PHI ( Protected Health Information), a proxy is someone who has been granted permission to access the PHI of another individual. The most common proxy relationship is that of a parent accessing his or her child’s PHI.

How do I become a Proxy?
You must be invited by an individual to have access to his or her Protected Health Information. In the case of adult-to-adult proxy access, this can be accomplished through your Follow My Health account settings, without the need to contact Visalia Medical Clinic.
See invite a proxy to your PHI.

If you are the parent or guardian of a minor child (under the age of 13) who is a patient of Visalia Medical Clinic, we will send you an invitation for proxy access via email. Please fill out and print the Proxy Request form and deliver it in to your health care provider or representative.

Why can’t I email this form?
In an effort to comply with federal privacy and security regulations, including HIPAA, we cannot send or receive unencrypted patient information through email or other electronic means. Please submit your completed forms to your health care provider or their staff.

What if my child is 13 or older?
California State law grants children 13 years and older the right to keep their Protected Health Information private, even from their primary guardians. (California Health and Safety Codes 123110 & 123115) For this reason we are not able to grant access to the PHI of young adults ages 13 through 17.
Find out more here. What happens when a child reaches the protected age.

During the setup, after you’ve received the email, you will be asked for a Security Code. The code will be the 4-digit year of birth of the requesting Parent/Guardian. (example: 1984)


Click here to print Proxy Request form.

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