Get Mychart Baton Rouge Clinic

This guide provides comprehensive instructions on filling out the MyChart Teen Proxy Form for accessing the online medical record of a patient aged 15 to 17. Follow these steps carefully to ensure successful completion of the form.

Follow the steps to fill out the MyChart Teen Proxy Form effectively.

1. Click 'Get Form' button to obtain the Teen Proxy Form and open it in the editor.
2. Complete the 'Parent Information' section, ensuring to fill in all required fields clearly. This includes entering the full name (last, first, middle initial), date of birth, social security number, email address, street address, city, state, zip code, phone number, and primary clinic.
3. Next, fill out the 'Patient’s Information' section with details about the patient whose MyChart record you are requesting access to. Similar to the parent section, ensure all fields are completed clearly.
4. Read through the 'MyChart Terms and Agreement' carefully. You will need to confirm your understanding and agreement by signing at the designated place.
5. In the 'Teen Proxy Authorization for Release of Medical Information' section, the patient must provide their name and social security number, date of birth, and explicitly state the name of the proxy who will have access to their health information.
6. The patient must then provide their signature, printed name, and date. If someone other than the patient is signing, note the authority to sign and attach documentation.
7. Finally, after completing all sections, review all information for accuracy, then save changes, download, print, or share the form as needed.

Complete your MyChart documents online today for efficient management of your medical records.