Portal Access Request | DPOA | McLaren Health Care

2 Physician Certifications Verifying Patient Lacks Decisional Capacity

Physician Certifications Documentation (1)

Physician Certifications Documentation (2)

I hereby affirm that am the Durable Power of Attorney for Healthcare of the patient identified above and I understand that submitting false information might lead the revocation of my access to McLaren HealtheLife Portal.

Confirm

I understand that if the above patient regains decisional capacity and I am no longer able to serve as Durable Power of Attorney must notify McLaren HIM of change in status immediately.

Confirm

Male	Female
Both	Unknown

Aunt or Uncle	Brother
Child	Cousin
Daughter	Father
Foster Child	Foster Parent
Friend	Grandchild
Grandfather (Maternal)	Grandfather (Paternal)
Grandmother (Maternal)	Grandmother (Paternal)
Guardian	In-Law
Life Partner	Mother
Niece or Nephew	Overage Dependent
Parent	Self
Sibling	Sister
Son	Spouse
Stepchild	Stepparent
Ward

Male	Female
Both	Unknown

MRN	Date of Service
SSN	I do not have

Last four of your SSN	Year you got married
Year you graduated high school	Year your father graduated high school
Year your father was born	Year your mother graduated high school
Year your mother was born	Your postal code

Request for Adult Seeking Access via Durable Power of Attorney to McLaren HealtheLife Portal

Guardian Information

Patient Information

Legal Documents Required: