Article Structure
The Con 160 form, often referred to as the Child Proxy Form for MyChart, plays a crucial role in enabling parents or guardians to access their child's health information through The Everett Clinic's secure online portal. This form allows for the smooth registration of a parent or guardian as a proxy, thus granting them electronic access to their child's medical records held within MyChart. To complete the process, individuals are required to provide essential information, including the child's name, date of birth, and medical record number, as well as details about the parent or guardian, such as their own name, address, and contact information. It's essential to note age-specific regulations attached to the form: access is granted fully for children aged 0 to 12 years, while limitations affect access for those aged 13 and older. Within these parameters, the form outlines the responsibilities of the proxy, stressing the importance of maintaining security and confidentiality of medical information. Moreover, the execution of this form signifies an understanding of both the limitations and the responsibilities involved in accessing sensitive health records, including the necessity for consent once the child reaches a certain age, particularly regarding sensitive topics like mental health or reproductive health. This structure ensures that parents can remain informed about their child's health while adhering to legal standards that protect the privacy of young adults.
Con 160 Example
Not activated as of __________ |
Child Proxy Form |
MYChart
Child Proxy Form
Access to Your Child’s MyChart Account:
(Medical Record)
PATIENT LABEL HERE
OR
Patient Name____________________
Date of Birth_____________________
MRN____________________________
To sign up for access to your child’s MyChart, please complete and sign this Child Proxy Form and return it to the address shown below. If you are an Everett Clinic patient you will need to have an active MyChart account in order to access your child’s MyChart. If you are not a patient at The Everett Clinic, we will set up an account for you once this form has been processed.
Return all forms to: The Everett Clinic or Fax: (425)
Everett, WA 98201
Parent/Guardian Information: (Completion of all sections is required
Name (last, first, middle initial): __________________________________________________________
Date of Birth: ____________________
Street Address: _______________________City: ___________State:_____________ Zip:___________
Please note the following age range limitations for MyChart. These age range limitations do not affect any
legal right you have to access your child’s record by other means. To request a copy of your child’s record in paper or electronic format, contact the Health Information (Medical Record) Department at The Everett Clinic.
•If your child is age
•Once your child reaches age 13, you will have limited access to your child’s MyChart (see below).
The following information is needed for proxy access: (All fields are required. A form must be provided for each child.
If you need additional forms, request another proxy access form from the Health Information (Medical Record) Department or print one from www.everettclinic.com/MyChart).
Name (last, first, middle initial): __________________________________________________________________
Date of Birth: ________________________
MyChart Terms and Agreement
•I understand that MyChart is intended as a secure online portal for viewing confidential medical information.
If I share MyChart ID and password with another person, that person may be able to view my or my child’s health information, and health information about someone who has authorized me as a MyChart proxy.
•I agree that it is my responsibility to select a confidential password, to maintain my password in a secure manner, and to change my password if I believe it may have been compromised in any way. I understand that MyChart contains selected, limited medical information from a patient’s medical record and that MyChart does not reflect the complete contents of the medical record. I also understand that a copy of a patient’s medical record may be requested from The Everett Clinic.
•This form only authorizes access through MyChart and does not authorize release of medical records by other methods or in other formats.
•I understand that once information has been disclosed, it potentially may be
•I am aware that The Everett Clinic does not condition any health care treatment, payment, or other services on signing this authorization.
Child Proxy Form (page 2)
•I understand that patients age 13 and above must consent for the release of information for treatment of mental health and/or substance abuse and patients age 14 and above must consent for the release of information of treatment for birth control and/or sexually transmitted diseases. I understand that my activities within MyChart may be tracked by computer audit and entries I make may become part of the medical record.
•I understand that access to MyChart is provided by The Everett Clinic as a convenience to its patients and that The Everett Clinic has the right to deactivate access to MyChart at any time for any reason. I understand that use of MyChart is voluntary and I am not required to use MyChart or to authorize a MyChart proxy.
By signing below, I acknowledge that I have read and understand this MyChart
•This proxy authorization will expire in 90 days if the associated MyChart account is not activated within that time period.
______________________________________________/___________________________/____________________
Signature of Parent/Guardian Relationship to Patient Date (Required)
This form will be scanned into the patient’s chart
Form Characteristics
| Fact Name | Details |
|---|---|
| Form Purpose | This form allows a parent or guardian to gain access to a child’s MyChart account, providing a way to view medical records online. |
| Activation Requirement | The parent or guardian must have an active MyChart account with The Everett Clinic to access the child’s account. |
| Age Range Limitations | For children age 0-12, parents receive full access. At age 13, access becomes limited, and special rules apply for mental health information. |
| Information Required | Parents must complete all sections of the form, including their own name, date of birth, address, email, and phone number. |
| Proxy Access | A separate form is needed for each child. Parents can request more forms from the Health Information Department or download them online. |
| Expiration of Access | The authorization will expire 90 days after submission if the MyChart account remains inactive. |
| Disclosure Risks | Once shared, information may be re-disclosed. The parental consent does not extend to all medical records or other formats. |
| Deviation from Standard Practices | This form does not condition healthcare services on whether the proxy is signed, ensuring patient rights remain intact. |
| Governing Law | This form is governed by Washington State law regarding medical record access and patient privacy. |
Guidelines on Utilizing Con 160
To gain access to your child's MyChart account, it is essential to complete the Con 160 form accurately. This step-by-step guide will help you navigate through the process, ensuring that every section is filled out properly to facilitate a smooth application experience.
- Begin by downloading the Con 160 form from the designated website or receiving a copy from the Health Information (Medical Record) Department.
- Enter your child’s name in the indicated section. Use their last name, first name, and middle initial.
- Provide your child’s date of birth on the corresponding line.
- Fill out your own details in the "Parent/Guardian Information" section. Include your name (last, first, middle initial), date of birth, street address, city, state, and zip code.
- Include your email address to facilitate communication regarding your MyChart access.
- Enter your phone number where you can be reached.
- Complete the information required for proxy access. This includes your child's name and date of birth once again, ensuring accuracy.
- Review the MyChart Terms and Agreement. It’s crucial to read each statement carefully to understand your responsibilities regarding confidential information.
- Sign the form by writing your name, indicating your relationship to the patient, and dating your signature. This step confirms that you agree to the terms outlined.
- Double-check all entries to ensure clarity and correctness, as this will help speed up the processing of your request.
- Submit the completed form. You can either mail it to The Everett Clinic or fax it to the provided number (425-339-5439). Ensure it is sent to the Medical Records department at the address listed in the instructions.
Following these steps meticulously will help ensure that your child's MyChart account can be accessed without delay, allowing you to manage their health information efficiently. Pay special attention to the deadlines and conditions mentioned to avoid any issues with access.
What You Should Know About This Form
What is the purpose of the Con 160 form?
The Con 160 form, also known as the Child Proxy Form, allows a parent or guardian to request access to their child’s MyChart account. This access enables the authorized person to view confidential medical information and manage appointments on behalf of the child.
How do I submit the Con 160 form?
After completing the Con 160 form, submit it to The Everett Clinic. You can return the form by mail to the address listed on the form or fax it to (425) 339-5439. Ensure that all required sections are filled out clearly.
Who is eligible to complete the Con 160 form?
A parent or legal guardian can complete the form to access their child's MyChart account. It is crucial that the person filling out the form has the legal right to access the child's medical records.
What age limits apply to MyChart access for children?
Access is granted based on the child's age. For children ages 0 to 12, full access is provided. Once the child turns 13, access may be restricted regarding certain sensitive information, unless consent is given by the child.
What should I do if I need forms for more than one child?
If you require access for multiple children, you must complete a separate Con 160 form for each child. Additional forms can be requested from the Health Information (Medical Record) Department or printed from The Everett Clinic's MyChart website.
What are the security responsibilities associated with MyChart?
As a proxy, it is your responsibility to maintain the security and confidentiality of your MyChart password. If the password is believed to be compromised, it should be changed immediately. Sharing your MyChart ID and password could allow others to access sensitive medical information.
Does signing the Con 160 form guarantee access to medical records?
No, completing the Con 160 form only grants access to view information through MyChart. It does not authorize the release of the medical records through other means or formats. Requests for copies of medical records must be made separately.
How long does the proxy authorization last?
The authorization period for proxy access is 90 days. If the associated MyChart account is not activated within this time frame, the authorization will expire, and a new form will need to be submitted for access.
Common mistakes
Filling out the CON 160 form requires careful attention to detail, yet many individuals encounter challenges that can delay or prevent the processing of their child’s MyChart access. One common mistake occurs when the parent or guardian does not complete all required sections of the form. Instances of incomplete information, such as leaving out essential details like the child’s name or the parent’s contact information, can lead to significant delays. Clarity is vital; unclear handwriting can also complicate matters. Ensure all sections are filled out clearly and completely.
Another frequent misstep involves misunderstanding the age-related limitations associated with MyChart access. Parents may not fully grasp that access changes once a child reaches the age of 13. Limited access rights for children in this age group necessitate additional consent. Failing to acknowledge these regulations may cause confusion and result in an inability to access specific information. It is essential to be informed about these age restrictions when filling out the form.
Providing the appropriate signatures is yet another critical area where mistakes can arise. Some applicants forget to sign the form or neglect to include the date. Both the signature and date of the parent or guardian are essential for consent, as they signify the agreement to the terms outlined in the MyChart agreement. It is advisable to double-check that the signature is present and that it is dated correctly, ensuring that all necessary authorizations are in place.
Finally, sending the form to the wrong address is a mistake that can easily be made, particularly in today’s digital age where electronic communication is prevalent. Ensuring the form is sent to the correct mailing address or fax number is crucial. To avoid this pitfall, read the directions carefully and verify that the submission is directed to the appropriate department at The Everett Clinic. Double-checking this information can help streamline the process and prevent unnecessary delays.
Documents used along the form
When completing the CON 160 Child Proxy Form, several other documents may also be needed to ensure proper access and management of a child’s medical information. Each of these forms serves a specific purpose and is crucial in maintaining the integrity and confidentiality of the child's health records.
- Medical Records Request Form: This form is used to formally request copies of a child's medical records from the healthcare provider. It specifies the information needed and authorizes its release.
- Authorization to Release Information: This document allows healthcare providers to share a patient’s medical information with specific individuals or entities. It is particularly important when third parties need access for legal or insurance purposes.
- MyChart Registration Form: This registration form is necessary for establishing a MyChart account if the parent or guardian does not already have one. It collects personal information required for account creation.
- Proof of Relationship Documentation: Sometimes, documentation proving the relationship between the adult and the child might be required. This could include a birth certificate or legal guardianship papers.
- Privacy Notice Acknowledgment: Patients usually need to acknowledge the healthcare provider's privacy policies regarding the handling of personal health information. This ensures that caregivers understand their rights and the safeguards in place.
- Parental Consent for Treatment: This form is necessary if the child is undergoing medical treatment and consent must be obtained from a parent or legal guardian.
- MyChart Terms of Service Agreement: Users must sign this agreement to understand the terms under which they can access and use MyChart, including privacy considerations and user responsibilities.
- Child Emancipation Documentation: If applicable, this documentation proves that a minor has been legally declared emancipated and may require different forms of consent for medical access.
- HIPAA Authorization Form: This form ensures compliance with the Health Insurance Portability and Accountability Act (HIPAA) when releasing or obtaining medical information. It specifies who can share information and under what circumstances.
Having these documents ready when submitting the CON 160 form can help streamline the process and enhance access to a child's medical information. Proper documentation not only protects the privacy of the child but also ensures that parents and guardians have the necessary tools to manage their child's healthcare effectively.
Similar forms
-
HIPAA Release Form: Similar to the Con 160 form, a HIPAA release form allows parents or guardians to access a child's medical information. Both documents emphasize the need for clear consent and provide regulations regarding the handling of sensitive health information.
-
Child Authorization Form: This form is often used in healthcare settings to designate individuals who can make medical decisions for a minor. Like the Con 160, it requires personal details of the parent or guardian and the child, ensuring proper identification and authorization for access.
-
Proxy Access Agreement: A proxy access agreement allows a person to act on behalf of a patient in accessing their health information. Both the Con 160 and proxy access agreements require signatures and outline the responsibilities of the proxy to protect the confidentiality of the patient’s information.
-
Patient Information Release Form: This document grants permission for healthcare providers to release medical records to a specified individual. Similar to the Con 160 form, it highlights the importance of patient consent and provides guidelines to ensure information is shared securely and compliantly.
Dos and Don'ts
When completing the Con 160 form, adhering to proper protocols can ensure a smooth process. Below is a list of things you should and shouldn't do:
- Do: Print clearly in all sections to ensure legibility.
- Do: Provide accurate information, including your child's name and date of birth.
- Do: Check that you meet the age range requirements before applying for MyChart access.
- Do: Sign and date the form where indicated to validate your application.
- Don't: Leave any required fields unanswered, as incomplete forms may be rejected.
- Don't: Share your MyChart ID and password with anyone, which could compromise your and your child’s privacy.
Misconceptions
- MyChart is a Complete Medical Record: Many people believe that MyChart provides a full view of a child's medical history. However, MyChart contains only selected, limited information. For a complete medical record, a formal request must be made to The Everett Clinic.
- Proxy Access Means Unlimited Access: A common misconception is that granting proxy access allows the parent unlimited access to a child's records. In reality, access varies with the child’s age, especially after they turn 13.
- Access is Automatic: Some may think they will automatically receive access once the Con 160 form is filled out. Access is only granted after the MyChart account has been activated.
- All Children Can Have Proxy Access: It's often misunderstood that any child of any age can have their records accessed by a parent. In fact, specific age limitations apply to the proxy access, particularly for children 13 and older.
- MyChart is Always Active: Individuals sometimes assume that once they sign up, their MyChart access will remain indefinitely. However, this authorization expires after 90 days if the MyChart account is not activated.
- Only Patients Can Use MyChart: Some believe that only current patients of The Everett Clinic can use MyChart. If you are not a patient, an account can still be created once the Con 160 form is processed.
- No Need for a Secure Password: A misconception is that a secure password is not important. However, it's crucial to maintain a confidential password to protect sensitive information.
- The Clinic is Responsible for MyChart Security: Many think the clinic is fully responsible for the security of their access. However, it’s the responsibility of the parent or guardian to keep their login credentials safe.
- Signing the Form Means You Have to Use MyChart: There’s a belief that signing the authorization requires the use of MyChart. In reality, using MyChart is voluntary; one can choose to access records by other means.
Key takeaways
The CON-160 Child Proxy Form is necessary for a parent or guardian to gain access to their child's MyChart account, which contains medical information.
Completion of all sections of the form is mandatory. It's important to print clearly to avoid any misunderstandings.
Access is granted based on the child's age. Parents can access information for children aged 0-12 without limitations.
When a child turns 13, parent's access to MyChart becomes limited. Parents should be aware of the specific restrictions in place.
Each child requires a separate proxy form. If you have multiple children, you will need to complete one for each.
Proxy access can only be set up after the parent or guardian has an active MyChart account at The Everett Clinic.
The form needs to be returned either by mail or fax to the Medical Records Department to be processed.
Once the form is processed, access to the MyChart account should be activated within 90 days, or the authorization will expire.
Bear in mind that MyChart is a secure portal designed to protect confidential medical information. Sharing login details is discouraged and can lead to unauthorized access.
Understanding the MyChart terms is crucial. The user acknowledges responsibility for maintaining secure passwords and agrees to the potential for monitored activity within the account.
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