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CHILD/ADOLESCENT 12-17 YEARS PROXY REQUEST

restraining orders in effect limiting the parent’s, permanent legal guardian’s or Proxy’s access to the Patient’s medical ... [The parent / permanent legal guardian must read and sign the following statement.] By ... revoke this Authorization Form and the Proxy’s MyChart access at any time by writing and mailing a request, completing ...

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  Testament, Writing, Restraining

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Transcription of CHILD/ADOLESCENT 12-17 YEARS PROXY REQUEST

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