You must be the parent or legal guardian of a child under the age of 13. If you are the legal guardian, you will need to have proof of legal guardianship in the child’s record or you can attach the proof of guardianship along with your completed form.

You must be the parent or legal guardian of a child age 13 to 17 years old. If you are the legal guardian, you will need to have proof of legal guardianship in the child's record or you can attach the proof of guardianship along with your completed form.

Use this request if you meet one of the following:

1. You have legal healthcare power of attorney for the patient (Proof of power of attorney will need to be on file in the patient’s medical record or you can attach the legal documentation with your request form.)
2. You are the patient’s personal representative (e.g., parent, legal guardian, etc.) and the patient lacks capacity to consent due to medical reasons.

View instructions if your loved one is over 18 and can consent.