Personal Represenotis e's Name (it Applicable Dale: —4- - I I- I? Personal Representatise's Authorits tc.g., parent, guardian, health ran prosy): Effectist as of 1110112017. EFTA00304452 ACCESS YOUR HEALTH INFORMATION ONLINE IIENEFrf S OF MYCHART Ai UP YOUR ACCOUNT SECURITY OF YOUR NEALTI4 INFORM