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Pediatric Proxy Access Request Form (011 years old)GCS Chart is a secure, online tool that connects you to portions of your GHC electronic health record. To request access to Chart, please read this
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How to fill out pediatric proxy access request

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How to fill out pediatric proxy access request

01
Go to the hospital or healthcare provider's website.
02
Look for the section on patient information or patient resources.
03
Find the pediatric proxy access request form.
04
Fill out the form with your child's information, your information as the parent or guardian, and any other requested information.
05
Submit the form according to the instructions on the website or by mailing it to the appropriate address.

Who needs pediatric proxy access request?

01
Parents or legal guardians who need access to their child's medical records and information.
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Pediatric proxy access request is a form allowing a parent or guardian to access a child's medical records or make decisions on their behalf.
A parent or legal guardian of a minor child is required to file a pediatric proxy access request.
To fill out a pediatric proxy access request, the parent or guardian must provide their information, the child's information, and sign the form.
The purpose of pediatric proxy access request is to ensure that a parent or guardian has the legal authority to access a child's medical information or make decisions on their behalf.
The pediatric proxy access request must include the parent or guardian's name, contact information, relationship to the child, and the child's name and date of birth.
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