Proxy Access and Authorization Form

This form should be completed by a parent or permanent legal guardian (“Proxy”) who wants to request access to your child’s My CS-Link Record or Cedars-Sinai Connect (as applicable) The Proxy will need to complete photo ID verification and/or provide relevant legal or court documents asserting their right to make such request.

Access to the child, or teen’s My CS- Link Record or Cedars-Sinai Connect (as applicable) will be through your My CS-Link Account or Cedars-Sinai Connect (for Cedars-Sinai Connect visits). 

Please note the following information regarding Proxy Access as it relates to each age group:

  • Child Proxy– If the patient is a minor between the ages of 0-11, Proxy will be granted full access to the minor patient’s information in My CS-Link Record, and, with respect to Cedars-Sinai Connect visits, to Cedars-Sinai Connect, until the child reaches age 12. The day before the 12th birthday of the patient, all proxy access is automatically switched to no access. 
  • Teen Proxy– If the patient is a minor between the ages of 12-17, Proxy access is limited to ensure privacy for our patients in accordance with the California Confidentiality of Medical Information Act (CMIA) State Laws around adolescent confidentiality rights.  For example, in proxy’s My CS-Link Account, Proxy will not have access to certain aspects like teen’s medical notes or test results but can view teen’s upcoming visits with all providers and message providers on behalf of teen. In Cedars-Sinai Connect, proxy will have access to the teen’s visit information and care plan provided by a Cedars-Sinai Connect clinician.  The day before the 18th birthday of the patient, all proxy access is automatically revoked and new proxy access must be pursued to re-establish proxy access, if the patient desires.

User Acknowledgment of Terms and Conditions for Use of Cedars-Sinai My CS-Link Record*.

By accepting, I acknowledge and agree that as the Proxy: 

  1. I will be using my own My CS-Link account or the patient profile under my Cedars-Sinai Connect account (as applicable) to access the patient’s record, for whom I am requesting proxy access.
  2. I will comply with the terms and conditions on the My CS-Link web page (located at, then select the Terms and Conditions link on the page) ,this document and any document I consent to in Cedars-Sinai Connect.  
  3. I will keep my password confidential and not share this information with anyone.
  4. I must have parental rights or permanent legal guardianship rights or the patient’s consent to access this patient’s record.
  5. I have not been denied periods of physical placement with the patient and there are no court orders or restraining orders in effect limiting my access to this patient’s medical records and/or information.
  6. Communications on behalf of the patient through My CS-Link must be sent from the patient’s record and responses will be received in the patient’s record. 
  7. There are age range limitations for My CS-Link or Cedars-Sinai Connect (applicable). These age range limitations do not affect any legal right I have to access the patient’s record by other means. Furthermore, I understand that Cedars-Sinai My CS-Link Chart and/or or Cedars-Sinai Connect does not reflect the complete contents of the medical record, and I can request a paper copy of the patient’s record by contacting the Health Information Department at 310-423-2259. 
  8. For a patient age 0 to 11 years, I will be granted full access to the patient’s My CS-Link Records record.  On the patient’s 12th birthday, I will no longer have access to the patient’s My CS-Link or Cedars-Sinai Connect record.
  9. For a patient 12-17 years, I will be granted limited access due to California State confidentiality laws specific to teen patients. On the patient’s 18th birthday, I will no longer have access to the patient’s My CS-Link or Cedars-Sinai Connect record.
  10. On Cedars-Sinai Connect, for patients 0-17 years, I will be granted access only to records of visits with Cedars-Sinai Connect clinicians.
  11. I authorize the Use or Disclosure of Electronic Protected Health Information.
  12. I understand that access to Cedars-Sinai My-CS Link Record or Cedars-Sinai Connect (as applicable) is provided by Cedars-Sinai as a convenience to its patients and that Cedars-Sinai has the right to deactivate access to My CS-Link Record or Cedars-Sinai Connect (as applicable) at any time for any reason. I understand that the use of My CS-Link Record is voluntary and that I am not required to use Cedars-Sinai or to authorize My CS Link or Cedar-Sinai Connect proxy. Cedars-Sinai reserves the right to revoke online access to My CS-Link and or Cedar-Sinai Connect at any time. 
  13. I understand that in some cases lab/test results will be released without prior provider review or without prior consultation between patient and the health care provider.
  14. If my legal status changes, I will notify Cedars-Sinai Health Information Department at 310-423-2259.

This section is an authorization that will allow Cedars-Sinai to release your health information to your designated adult proxy.

Notice/Restriction: California law prohibits the Proxy Representative from making further disclosure of your health information unless the recipient obtains another authorization from you or unless the disclosure is permitted by law. This protection may not extend to recipients outside the state of California. This authorization does NOT allow my Proxy Representative to (1) make health care decisions of my behalf OR (2) access my health information other than via My CS-Link or Cedars Sinai Connect online.

Your rights/Expiration of Authorization: 

As the patient/patient representative, you have the right to request a copy of this authorization. 

Unless otherwise revoked, the authorization for My CS Link Record or Cedars-Sinai Connect (as applicable) access shall be valid for 5 years or until terminated by the patient or Proxy electronically or in writing. I may refuse to sign the authorization at any time electronically or in writing. If written, the revocation must be signed by me or in my behalf and sent to the Health Information Management Department via mail, fax, or email. 

Mail to: Cedars Sinai Medical Center, Health Information Management Department, 8700 Beverly Blvd., Room 2901, Los Angeles, CA 90048

Fax: 310-423-0113


The revocation is effective upon receipt but will have no impact on uses or disclosures made while the authorization was valid.

By accepting these terms, I accept the My CS-Link access disclosure and I acknowledge that I have read, understand, and agree to the My CS-Link Terms and Conditions.