MyChart -

To request proxy access, please complete the form below. We will contact you by phone or email if we have any questions regarding the information provided.

Step 1 | TELL US ABOUT YOU

Today's Date:

First Name:

Middle Initial:

Last Name:

Your Date of Birth:

Your Social Security Number:

Street Address:

City:

State:

Zip Code

Mobile Phone (xxx-xxx-xxxx):

Email Address:

Step 2 | PARTICIPANT INFORMATION:

Participant's First Name:

Participant's Middle Initial:

Participant's Last Name:

Participant's Date of Birth:

InnovAge Center

Your relationship to the Participant:

If other, please specify:

SECOND PARTICIPANT INFORMATION:

Participant's First Name:

Participant's Middle Initial:

Participant's Last Name:

Participant's Date of Birth:

InnovAge Center

Your relationship to the Participant:

If other, please specify:

THIRD PARTICIPANT INFORMATION:

Participant's First Name:

Participant's Middle Initial:

Participant's Last Name:

Participant's Date of Birth:

InnovAge Center

Your relationship to the Participant:

If other, please specify:

"YES, I sign this form electronically and certify that all information I have provided is correct. By signing this form, I acknowledge that I have read, understand, and agree to abide by the Terms and Conditions of Use posted on the MyChart website. I understand that a violation of such terms may result in loss of access to MyChart."

MyChart Activation Request: New Proxy Account

Step 1 | TELL US ABOUT YOU

Step 2 | PARTICIPANT INFORMATION:

SECOND PARTICIPANT INFORMATION:

THIRD PARTICIPANT INFORMATION: