Minor Proxy Form printable pdf download

PATIENT IDENTIFICATION LABEL

Minor Proxy Form (Age 17 and Under)

• I understand that MyLVHN is not to be used for medical emergencies or urgent situations.

• I understand that MyLVHN Proxy provides access to personal health information regarding the child or children

17 years of age and under listed on this form.

• The information disclosed in MyLVHN will allow me to play a more active role in the healthcare of the child. I

understand this is not the child’s complete record, though an electronic or paper copy may be requested at the

physician’s practice.

• I understand that my activities within MyLVHN are tracked by computer audits and that entries I make may

become part of the medical record of the child.

• I understand that a written request must be made to cancel or revoke this authorization and that any actions

taken or access prior to cancellation was authorized by my signature and date on the "Minor Proxy Form."

• I understand that Lehigh Valley Health Network has the right to revoke access of MyLVHN at any time for

abusive use of the system. I understand that when the child turns 18 years old, my access to their MyLVHN

account will be automatically terminated and an Adult Proxy Form would be required at the consent of the 18

year old child.

• I understand that should my child become emancipated, my access to my child’s medical records using

MyLVHN will be immediately terminated, and a new proxy access must be granted.

I have read and understand the requirements and procedures for accessing a child’s medical record

information online as provided in this proxy consent form.

I certify that all of the information I have provided is correct. I hereby request access to my child’s online

medical record. I have provided Lehigh Valley Health Network with legal documentation providing I am the

parent or legal guardian of the child whose health information I will be accessing through MyLVHN.

Signature of Parent/Guardian

Date (Month/Day/Year)

Office Use Only

Patient’s Medical Record Number:

Proxy Accounts Linked

Form Scanned

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Minor Proxy Form