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Medical Record No. Patient Name Birthdate Physician Please align patient label to the right(PTH)Chicago, IL 60611 Developmental Behavioral Clinic Questionnaire Infant and Toddler MR# Date Received:

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How to fill out proxy form 12-17 mychart

01

To fill out proxy form 12-17 mychart, follow these steps:

02

- Obtain the proxy form 12-17 mychart from the relevant authorities or website.

03

- Fill in the patient's personal details, including their name, date of birth, and contact information.

04

- Provide the proxy's personal details, including their name, relationship to the patient, and contact information.

05

- Specify the duration for which the proxy authorization is valid.

06

- Sign and date the proxy form.

07

- Submit the filled-out form to the appropriate department or individual responsible for processing proxy requests.

08

- Keep a copy of the filled-out form for your records.

Who needs proxy form 12-17 mychart?

01

Proxy form 12-17 mychart is required by individuals who are between the ages of 12 and 17 and wish to appoint a proxy to access and manage their health information in the mychart system. This could include minors who are unable to give consent or make decisions on their own, and require a trusted adult or guardian to act on their behalf.

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What is proxy form 12-17 mychart?

Proxy form 12-17 mychart is a form used to designate a proxy to act on behalf of an individual in managing their mychart account.

Who is required to file proxy form 12-17 mychart?

Any individual who wishes to authorize someone else to access and manage their mychart account needs to file proxy form 12-17 mychart.

How to fill out proxy form 12-17 mychart?

Proxy form 12-17 mychart can be filled out by providing the necessary information about the individual granting proxy access and the person being designated as the proxy.

What is the purpose of proxy form 12-17 mychart?

The purpose of proxy form 12-17 mychart is to allow individuals to grant someone else access to their mychart account for managing and viewing health information.

What information must be reported on proxy form 12-17 mychart?

Proxy form 12-17 mychart requires information such as the name and contact details of the individual granting proxy access, as well as the name and relationship of the designated proxy.

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