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Adult Proxy Authorization for Release of Medical Information

WEBThis form is an authorization that will permit providers utilizing The Queen’s Health Systems (QHS) Electronic Health Record (EHR) system to release your medical information in …

Actived: 3 days ago

URL: https://mychart.queens.org/mychart//en-us/QHS%20Adult%20Proxy%20Combined%202013.pdf

Child/Teen Proxy Form

WEB2 MyChart Agreement As a parent/guardian proxy, I understand that: o MyChart is intended as a secure online source of confidential medical information.

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