Child Proxy Form printable pdf download

PT NAME

*CONSNT*

MR #

* C O N S N T *

This form is used to: Access to Your Child’s One Chart | PATIENT account online (Legal Parent)

To request access to your child’s One Chart | PATIENT record, please complete this Child Proxy

Form and return it to the address below. Please allow 14 business days for processing after receipt

of your complete application. Please note, your child’s chart will be accessed through your One

Chart | Patient portal log-in.

Your Information: (All sections required – please print clearly.)

Name (last, first, middle initial) ___________________________________________________________

Date of Birth:_________________________

Last 4 digits of SSN: _______________

Street Address: ___________________________ City:_________________ State:_______ Zip:_______

Email Address: ________________________________________ Phone Number:__________________

Once your child reaches age 19, he/she is no longer a minor under Nebraska law and you will no longer have

access to his/her One Chart | PATIENT record. Your child may apply for his/her own log-in at age 19.

Please provide the following information for each child. All fields are required.

A. Name (last, first, middle initial)_____________________________________________________________________________

Date of Birth:__________________________________ Primary Clinic: ____________________________________________

B. Name (last, first, middle initial) _____________________________________________________________________________

Date of Birth:__________________________________ Primary Clinic: ____________________________________________

C. Name (last, first, middle initial) _____________________________________________________________________________

Date of Birth:__________________________________ Primary Clinic: ____________________________________________

D. Name (last, first, middle initial) _____________________________________________________________________________

Date of Birth:__________________________________ Primary Clinic: ____________________________________________

ONE CHART Attestation

• By signing below, I am certifying to the fact that I am the legal parent of the child(ren) listed above and have all right

and authority to view his/her/their medical information.

• I acknowledge that it is my responsibility to keep my One Chart | PATIENT log-in information confidential or risk others

having access to the confidential information contained therein.

• I understand that One Chart | PATIENT contains selected, limited medical information from a patient’s medical record

and that One Chart | PATIENT does not reflect the complete contents of the medical record. I also understand that a

paper copy of a patient’s medical record may be requested from my provider.

• I understand that my activities within One Chart | PATIENT may be tracked and that entries I make may become part of

the medical record.

• I further agree to abide by the Terms and Conditions of use of One Chart | PATIENT which I have the responsibility to

review.

_________________________________________________________________________________________________________

Signature of Parent (Required)

Relationship to Patient

Date

Return Form to: 10304 Crown Point Avenue, Omaha, NE 68134-9100

PROXY SET UP COMPLETED BY _____________________CLINIC STAFF? YES____

NO_____

Please send completed form to Zip 9100

Clinic Name

Proxy completed by:______________________________________________________________________________

Print Full Name

Date

CHILD PROXY FORM

CONSENT

CON-MR-0180 (rev. 9/15)

Child Proxy Form

Related Articles

Related forms

Related Categories