Get Pediatric Proxy Request Form - Myochsner - Ochsner Health System

This guide provides clear and detailed instructions for completing the Pediatric Proxy Request Form online for Ochsner Health System. By following these steps, you will ensure that the proxy access process is efficient and straightforward.

Follow the steps to complete your Pediatric Proxy Request Form online.

1. Click ‘Get Form’ button to acquire the Pediatric Proxy Request Form and open it for completion.
2. Fill in the patient's name, clinic number, street address, and date of birth in the designated fields. Ensure all details are accurate to avoid processing delays.
3. Enter the proxy requestor's email address and telephone number. This contact information should belong to the individual requesting access.
4. Specify the name of the person requesting proxy access. This should be the individual understanding their responsibilities in managing the child's health information.
5. Indicate whether there is any court order or restraining order affecting the requestor's access to the patient's medical information. A checkmark (✓) in the appropriate box is required.
6. Sign and date the form as the parent or personal representative. This signature authorizes Ochsner Health System to release the patient's health information under the specified terms.
7. Select the relationship to the patient by marking the relevant checkbox (e.g., custodial parent, non-custodial parent, legal guardian). Ensure to provide any necessary legal documentation for certain roles.
8. If applicable, ensure that any circled relationships like 'durable power of attorney for healthcare' are accompanied by legal verification paperwork to substantiate the request.
9. Once all fields are completed and verified for accuracy, save the changes you made to the form.
10. Choose to download, print, or share the completed form depending on your preferred method for submission.

Complete your Pediatric Proxy Request Form online today to ensure proper access to your child's health information.