Get Uw Medicine Request For Minor Proxy Mychart Access

The UW Medicine Request for Minor Proxy MyChart Access form allows parents and guardians of children under 13 to request online access to their child's medical records. This guide will provide clear instructions on how to complete the form accurately and efficiently.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling out the patient information section. Enter the child's name in the format of Last, First, Middle Initial. Then, provide the child's date of birth and the last four digits of their Social Security number.
3. Next, complete the requestor information section. This includes entering your name using the Last, First, Middle Initial format, as well as your relation to the child, your date of birth, address, email address, and phone number.
4. Ensure that you have your photo identification ready. This can be provided in person, via mail, email, or fax.
5. Review and complete the declaration and acknowledgement section. You must affirm your status as the child’s birth or adoptive parent or legally recognized caretaker, and confirm that you have the right to make healthcare decisions for the child.
6. Understand the implications of proxy access. Read through the statements regarding the possibilities of sensitive information being included in the child's medical record, revocation of access, and the need to notify UW Medicine of any changes in your legal authority.
7. Sign the form, indicating your agreement to the conditions outlined. Make sure to print your name and include the date of signing.
8. For submission, you can save your changes and then print the form. Ensure all necessary documentation is included, such as your photo ID, before sending it to the designated Health Information Management contacts provided at the end of the form.

Complete your documentation online today to ensure timely access to your child's medical records.