What type of access can we help you with?

Please select an option below. Print the required form and return it to:

FirstHealth of the Carolinas
Privacy Office
PO Box 3000
Pinehurst, NC 28374
Fax: (910) 715-2398

En Español

Option 1

I am a PARENT or LEGAL GUARDIAN requesting access for a patient under 18 years old. There are no restrictions legally or otherwise preventing my legal right to access.

PARENT/LEGAL GUARDIAN PROXY Authorization for MyChart Dependent
Account- Minor Child

For children 13 -17 years old, the health information you'll be able to view will be limited. When your child turns 18, your access will be turned off completely. Your teen child can choose to give you full access in both of these cases by completing and submitting the proper forms - please see Option 3 . The access is changed at these ages because of legal requirements. These age limitations do not affect any legal right you have to access your child's record by other means.

I am a FirstHealth Patient	I am NOT a FirstHealth Patient

Option 2

I am a FAMILY MEMBER OR FRIEND requesting access to an adult or emancipated minor's health information in FirstHealth MyChart.

PERMANENT LEGAL GUARDIAN/HEALTHCARE POWER OF ATTORNEY
Authorization for MyChart “Dependent” Account

Patient is another competent adult	Patient is incapacitated or incompetent adult	Patient is incompetent emancipated minor

The patient must complete Option 3 to request that access be given to you. Note: You must have power of attorney or legal guardianship.

Option 3

I am a PATIENT requesting that access be given to another person.

PATIENT AUTHORIZATON - PROXY Access to My FirstHealth of the Carolinas MyChart Account

Need assistance? Call FirstHealth at (910) 715-2434.

*Access to another person's account is also known as proxy. Access by proxy will only be granted if, and only to the extent, deemed clinically appropriate and allowable under North Carolina and federal law. Proxy access is also conditioned to compliance with the FirstHealth MyChart Terms and Conditions.