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Home > Medical Center > Forms > Clinical Care Forms > Clinical Forms > Clinical Forms > THE CHILD UNDER 18 YEARS OLD: PARENT OR LEGAL GUARDIAN ACCESS TO MYCHART PROXY AUTHORIZATION FORM

form 110162 : THE CHILD UNDER 18 YEARS OLD: PARENT OR LEGAL GUARDIAN ACCESS TO MYCHART PROXY AUTHORIZATION FORM

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view  |  PDF document icon 110162_Parent or Guardian-MyChart-Proxy Auth Form.pdf — PDF document, 130 KB (134139 bytes)


  1. effective date:

    March 17, 2020
Clinical Form Request

To request a new revision of a Clinical form visit the HIS website.

 

To order multiple copies:

 

  1. Search for and choose the appropriate document. 
  2. Right click the document PDF
  3. Select “Copy shortcut”
  4. Send an email with the PDF form attached to hospcopy@virginia.edu and include the following information:
    • Your name
    • PTAO
    • Quantity
    • Contact/Delivery information

 

PLEASE INCLUDE SPECIFIC PRINTING INSTRUCTIONS (i.e. multi part form, NCR, etc...) 

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