Get Queens Mychart

The Queens MyChart is a tool designed to help individuals request access to the medical records of adults under their care. This guide provides clear instructions for completing the Adult Proxy Request Form, ensuring all sections are accurately filled.

Follow the steps to successfully complete the Adult Proxy Request Form.

1. Click ‘Get Form’ button to obtain the Adult Proxy Request Form and access it in your preferred editing software.
2. Begin by filling in your information in the 'Your Information' section. Ensure you provide your full name, date of birth, last four digits of your Social Security Number, street address, phone number, email, city, state, zip code, and primary clinic or provider if applicable.
3. Next, complete the 'Patient’s Information' section by entering the full name, date of birth, last four digits of the patient’s Social Security Number, street address, phone number, email, city, state, zip code, and primary clinic or provider if applicable for the patient whose records you want to access.
4. Read and understand the important information provided regarding MyChart usage and access. Confirm your understanding by indicating your agreement to the terms outlined.
5. Sign the form in the 'Your (Proxy) Signature' section, indicating your relationship to the patient and the date of signing.
6. If required, have the patient or their legal representative sign in the 'Signature of Patient (or legal representative)' section, alongside their relationship to the patient and the date.
7. Finally, review the completed form for accuracy, save your changes, download a copy for your records, and return the finished form either to the provider’s office or to The Queen's Medical Center, MyChart Medical Records.

Complete your Adult Proxy Request Form online today to facilitate access to healthcare records.