Guardian Power Of Attorney Access Page 3

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Medical Record No.
(5230)
Patient Name
Birthdate
Physician
Please align patient label to the right
Proxy Form (Guardian Power of Attorney 12 and Over)
Please send this completed form via postal mail or fax to your child’s primary clinic location.
Ann & Robert H. Lurie
Children’s Hospital of Chicago
Health Information Management
225 E. Chicago Ave, Box 11
Chicago, IL 60611
Fax: 312-227-9733
Child and Adolescent Health Associates
Pediatric Associates of the North Shore
1030 N. Clark St., Suite 400
1144 Wilmette Ave.
Chicago, IL 60610
Wilmette, IL 60091
Fax: 312-943-6924
Fax: 847-256-6482
Children’s Healthcare Associates
Pedios, Ltd.
2835 N. Sheffield Ave. Suite 501
260 Chicago Ave.
Chicago, IL 60657
Oak Park, IL 60302
Fax: 773-348-7163
Fax: 708-383-0811
Karin Fiedler, MD
Rappaport Pediatrics, S.C.
5600 W. Addison St. #501
570 Lincoln Ave. Suite 1
Chicago, IL 60634
Winnetka, IL 60093
Fax: 773-282-8301
Fax: 224-255-6709
Lakeview Pediatrics
Streeterville Pediatrics
1525 W. Belmont Ave. #103
233 E. Erie St. #304
Chicago, IL 60657
Chicago, IL 60611
Fax: 773-472-7395
Fax: 312-280-1485
Milestone Pediatrics
Traisman, Benuck, Merens & Kimball
4043 Route 59
1950 Dempster St.
Naperville, IL 60564
Evanston, IL 60202
Fax: 630-420-8957
Fax: 847-869-4330
Northwestern Children’s Practice
680 N. Lake Shore Dr. Suite 1050
Chicago, IL 60611
Fax: 312-642-0753
Form 5230 Revised 10/16 HIM Approved 5/11
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