Instructions for Proxy Forms
You must be 18 years or older to register for MyChart. If you are younger than 18 years old, you will need to have your parent or guardian register on your behalf by completing the appropriate proxy form, which you can download in PDF format below.
For various reasons, we also allow adult-to-adult healthcare proxies. You can download this form below, as well.
You should return the completed form to your Shepherd Center via one of these methods:
- Use the Shepherd Center Zix Secure Email Portal to securely email your attachment to firstname.lastname@example.org. See this link for information on how to use Shepherd Center’s Secure Email Portal.
- Email using your email system to email@example.com.
- Send via U.S. mail to: Health Information Management, Shepherd Center, 2020 Peachtree Road NW, Atlanta, GA 30309.
- Fax to 404-603-4520.
|Download Adult Proxy Form||Download Child Proxy Form|
To request a proxy form for an adult with diminished cognitive capacity, send a request to firstname.lastname@example.org.