Get the free MyChart Proxy Form (12-17 yrs) (5229)4.16

Proxy Form (1217)Medical Record No. Patient Name Birthdate Physician Please align patient label to the rightward/Guardian Access to the Online Chart Record of a Patient 12 to 17 Years Old Requirements

How to fill out mychart proxy form 12-17

How to fill out mychart proxy form 12-17

1. To fill out the mychart proxy form 12-17, follow the steps below: 1. Obtain the mychart proxy form 12-17 from your healthcare provider or download it from their website.
2. Read the instructions on the form carefully to understand the requirements and guidelines for filling it out.
3. Provide your personal information in the designated fields, including your name, date of birth, address, and contact details.
4. Indicate the name of the minor whose information you are accessing as their proxy.
5. If applicable, provide any additional necessary information or documents as requested on the form.
6. Review the completed form to ensure all information is accurate and complete.
7. Sign and date the form to authorize your access as a proxy for the minor's mychart information.
8. Submit the completed form to your healthcare provider through the specified method, such as in-person delivery, fax, or mail.
9. Follow up with your healthcare provider to ensure they have received and processed your mychart proxy form 12-17.

Who needs mychart proxy form 12-17?

1. The mychart proxy form 12-17 is needed by individuals who are responsible for a minor's healthcare and need access to their medical records through the mychart system. This could include parents or legal guardians of the minor or anyone else who has been authorized by the minor's parent or legal guardian to act as their proxy for accessing their medical information.

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What is mychart proxy form 12-17?

Mychart proxy form 12-17 is a form that allows a designated individual to access and manage the medical information of a patient between the ages of 12-17.

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

A parent or legal guardian of a patient between the ages of 12-17 is required to file mychart proxy form 12-17.

How to fill out mychart proxy form 12-17?

To fill out mychart proxy form 12-17, the parent or legal guardian must provide their contact information, the patient's information, and sign the form to authorize access to medical records.

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

The purpose of mychart proxy form 12-17 is to allow parents or legal guardians to access and manage the medical information of patients between the ages of 12-17.

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

Mychart proxy form 12-17 requires information such as the parent or legal guardian's contact information, the patient's information, and the authorization to access medical records.