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CHILD PROXY FORM Please complete the following information for access to a minors MyChart account at Duly Health and Care (Duly). Proxy access for minors under 17 years of age will only be granted

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Gather all necessary information such as personal details, medical history, and insurance information.

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Who needs duly health and care?

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Anyone who wants to ensure they are receiving proper healthcare and coverage for medical costs.

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Individuals with existing medical conditions who require ongoing care and treatment.

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What is duly health and care?

Duly health and care is a form that needs to be filed with the health department to report information related to health and care services.

Who is required to file duly health and care?

Healthcare providers and facilities are required to file duly health and care.

How to fill out duly health and care?

Duly health and care can be filled out online or submitted in paper form with all the required information.

What is the purpose of duly health and care?

The purpose of duly health and care is to ensure that healthcare providers are compliant with health regulations and providing quality care.

What information must be reported on duly health and care?

Information such as patient demographics, services provided, and any incidents or complaints must be reported on duly health and care.

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