The patient must sign this form and provide authorization for release of medical information in MyChart on the "Adult. Proxy Authorization Form.Please complete the Authorization to Obtain Protected Health Information (PHI) from Another Provider to Wayne Memorial Hospital. By signing this authorization, you are agreeing to pay ScanSTAT Technologies for your records. To obtain a copy of a medical record, please use our Patient Central link above, or print and complete the Authorization for Release of Information. Streamline your OB new patient experience. Download and complete essential forms for your first appointment with us. 1 Pike Dr. Wayne, NJ 07470. The Authorization of Health Release Form enables family, friends, or others to obtain health information relating to individuals in custody. Medical Informed Consent Template for Adults: It is important to read this entire instruction page before you begin preparing this template.