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The form outlines eligibility guidelines, requires complete patient and parent/guardian contact details, and includes a proxy designation section authorizing Group Health Centre to release health information to a designated proxy. It also covers consent, voluntary participation, revocation terms, and physician internal approval.","Pediatric Proxy Access Request Form  \n(0-11 years old)  \nGHC’s MyChart is a secure, online tool that connects you to portions of your GHC electronic health record.  \nTo request access to MyChart, please read this form carefully and complete the appropriate fields below.  \nProxy Access to a Child’s MyChart:  \nParents/legal guardians may have access to a child’s MyChart based on the following guidelines. The child’s primary care provider/physician may determine that the child is capable of making his/her own decisions and ask for the child’s consent before allowing parent/legal guardian access to the child’s MyChart.  \nChildren between ages 0-11: The parent or guardian can be granted full access to the MyChart record upon approval of application. The patient will have access only with permission of the parent/ legal guardian or at the discretion of the primary care provider/physician.  \nPatient Information: (all sections required-please print clearly)  \nName (last, first, middle initial):  DOB:   Street Address:  City:   Province:  Postal Code:   Will the patient be accessing MyChart? If so, patient email is required.  \nEmail Address:  Phone Number:   \nParent/Guardian Information: (all sections required-please print clearly)  \nName (last, first, middle initial):   Relationship to patient:   DOB:    \nStreet Address:   City:   Province:   Postal Code:    \nEmail Address:   Phone Number:    \nHave questions about this form?  \nPlease contact Medical Records at (705) 759-5542.  \nCONTINUED ON NEXT PAGE  \nPediatric Proxy Access Request Form  \n(0-11 years old)  \nProxy Designation: (For those requesting access to a patient’s MyChart record)  \nThis section authorizes the Group Health Centre to release your personal health information to another individual such as a second guardian (proxy). Please read it carefully.  \nThis section should be completed by the patient or substitute decision maker who is authorizing another person to access personal information in his or her MyChart record.  \nMy Proxy’s information:  \n􀂆 Same as Parent/Guardian.  \nName (last, first, middle initial):   Relationship to patient:   Date of Birth:   Street Address:   City:   Province:   Postal Code:    \nEmail Address:   Phone Number:   This person is a designated MyChart proxy.  \n• I authorize GHC to release the health information contained in the MyChart record to this MyChart proxy.  \n• I authorize release of this information only through the MyChart Record. This form does not authorize release of my medical record to my designated proxy by other methods or in other forms.  \n• I understand that once information has been disclosed, it potentially may be re-disclosed by the proxy and the disclosed information may or may not be covered by privacy protections.  \nParticipation in MyChart and designating a MyChart proxy is completely voluntary. I understand that Iam not required to designate a MyChart proxy and I am not required to provide this authorization. I also understand that my health care treatment or other services will not be conditional on whether I provide this authorization. However, I also understand that if I do not provide authorization, GHC is not permitted to provide access to my MyChart record to my designated proxy.  \nI may revoke this authorization at any time by providing a written or verbal request for revocation to GHC Medical Records or my primary care provider’s office or completing the MyChart Deactivation Form. I understand that if I revoke this authorization, my designated proxy’s access to my MyChart record will be ended. I also understand my revocation will not affect any disclosures that were made prior to processing the revocation request.  \nPLEASE SIGN BELOW:  \nSignature of Patient (or authorized person)  \nSignature of Parent/Guardian or Proxy  \nDate  \nDate  \nFOR INTERNAL USE: 􀂆 HIM APPROVED  \nSignature of Physician/Primary Care Provider  \nDate","cbCailFl5jbuMSVW","https://ap.wps.com/l/cbCailFl5jbuMSVW","pdf",131524,2,"English","en",105,"# Patient Information\n# Parent/Guardian Information\n# Proxy Designation\n# Signatures and Dates\n# For Internal Use","[{\"question\":\"Who can request proxy access to a child’s MyChart?\",\"answer\":\"Parents or legal guardians may request access following guidelines. The primary care provider may determine whether the child is capable of making decisions and request the child’s consent before granting access.\"},{\"question\":\"What access is granted for children aged 0-11?\",\"answer\":\"For children between ages 0 and 11, the parent or guardian can be granted full access to the MyChart record upon approval of the application. The patient’s access is limited to permission from the parent/guardian or at the discretion of the primary care provider.\"},{\"question\":\"Can the authorization be revoked after it is approved?\",\"answer\":\"Yes. You may revoke the authorization at any time by submitting a written or verbal revocation request to GHC Medical Records or the primary care provider’s office, or by completing the MyChart Deactivation Form. Revocation ends the designated proxy’s access, but does not change disclosures made before the revocation was processed.\"}]","Pediatric Proxy Access Request Form - 0-11 Years Old | PDF",1791819919,{"code":4,"msg":75,"data":76},"ok",{"site_id":69,"language":68,"slug":77,"title":59,"keywords":78,"description":60,"schema_data":79,"social_meta":134,"head_meta":136,"extra_data":138,"updated_unix":139},"pediatric-proxy-access-request-form-0-11-years-old","",{"@graph":80,"@context":133},[81,96,116],{"@type":82,"itemListElement":83},"BreadcrumbList",[84,88,90,93],{"item":85,"name":86,"@type":87,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":89,"name":10,"@type":87,"position":66},"https://docshare.wps.com/template/",{"item":91,"name":36,"@type":87,"position":92},"https://docshare.wps.com/template/forms/",3,{"item":94,"name":59,"@type":87,"position":95},"https://docshare.wps.com/template/pediatric-proxy-access-request-form-0-11-years-old/563187/",4,{"url":94,"name":59,"@type":97,"image":98,"author":103,"headline":59,"publisher":105,"fileFormat":108,"inLanguage":68,"description":60,"dateModified":109,"datePublished":110,"encodingFormat":108,"isAccessibleForFree":111,"interactionStatistic":112},"DigitalDocument",{"url":99,"@type":100,"width":101,"height":102},"https://docshare.wps.com/thumbnails/pediatric-proxy-access-request-form-0-11-years-old/563187.png","ImageObject",442,249,{"name":57,"@type":104},"Person",{"url":85,"name":106,"@type":107},"DocShare","Organization","application/pdf","2026-10-19","2026-10-12",true,{"@type":113,"interactionType":114,"userInteractionCount":66},"InteractionCounter",{"@type":115},"ViewAction",{"@type":117,"mainEntity":118},"FAQPage",[119,125,129],{"name":120,"@type":121,"acceptedAnswer":122},"Who can request proxy access to a child’s MyChart?","Question",{"text":123,"@type":124},"Parents or legal guardians may request access following guidelines. The primary care provider may determine whether the child is capable of making decisions and request the child’s consent before granting access.","Answer",{"name":126,"@type":121,"acceptedAnswer":127},"What access is granted for children aged 0-11?",{"text":128,"@type":124},"For children between ages 0 and 11, the parent or guardian can be granted full access to the MyChart record upon approval of the application. The patient’s access is limited to permission from the parent/guardian or at the discretion of the primary care provider.",{"name":130,"@type":121,"acceptedAnswer":131},"Can the authorization be revoked after it is approved?",{"text":132,"@type":124},"Yes. You may revoke the authorization at any time by submitting a written or verbal revocation request to GHC Medical Records or the primary care provider’s office, or by completing the MyChart Deactivation Form. Revocation ends the designated proxy’s access, but does not change disclosures made before the revocation was processed.","https://schema.org",{"og:url":94,"og:type":135,"og:title":59,"og:site_name":106,"og:description":60},"article",{"robots":137,"canonical":94},"index,follow",{"doc_id":55,"site_id":69},1792382371]