Client Portal Proxy Form Ages 12-17 Mental Health Proxy From for ages 12-17A proxy authorization means that you give another person full access to your Credible Client Portal medical record through an online Client Portal account. It is as if they were you. This might be a parent or guardian who helps you take care of your health. You must complete the whole form.Child's InformationCHILDREN AGES 12-17 MUST SIGN THE FORM BELOW IN ORDER FOR THIS INFORMATION TO BE PROCESSED. All information MUST be filled out, if any information is missing, this will delay process:Date MM slash DD slash YYYY Client Name First Last Date of Birth MM slash DD slash YYYY Age Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Parent/Guardian (person requesting access):All information MUST be filled out or it will delay request.Name of Parent / Guardian Requesting Access: First Last Address of Parent / Guardian Requesting Access: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth MM slash DD slash YYYY Phone:Email Address to send verification code: Last four digits of SSN for child you are registering: Legal relationship to client: For parents/guardians who are divorced, separated and/or share custody of the minor child you, the parent asking for proxy rights, MUST show legal documentation indicating that you can have access to the child’s medical/mental health care.Northland Counseling Center, Inc. can release health information for the client to the proxy listed above through an online Client Portal account.Client Portal Agreement:Consent: I have read and understand the following:• For minors 0 to 11 years old, the proxy will have access to the minor’s Client Portal medical record until their 12th birthday; once the form is completed the child (age 0-11) does not need to sign this form. • For minors 12 to17 years old, if the minor does not sign this form, the proxy will not be given access of the Client Portal medical record. • For minors 12 to 17 years old who sign this form, the proxy will have full access to their Client Portal medical record for one year. The proxy will need to fill out a new authorization form each year to renew access. • Minors 12 to 17 years old can change their mind about proxy access to Client Portal at any time by letting Northland Counseling Center, Inc. know in writing. When Northland Counseling Center, Inc. gets the note, the change will be made no later than 3 business days. The change will not apply to information that has already been released before the effective date. • For parents/guardians who are divorced, separated and/or share custody of the minor child you, the parent asking for proxy rights, MUST show legal documentation indicating that you can have access to the child’s medical/mental health care. • Minor Patient Proxy Authorization ends when a patient turns 18 years old. • Northland Counseling Center, Inc. cannot be responsible for the privacy of information given to the proxy. Northland Counseling Center, Inc. cannot prevent the proxy from giving information to another person. At that time, the information is no longer protected by federal and state privacy rules. • If I do not sign this form, Northland Counseling Center, Inc. will still provide treatment to the client. This form will not affect payment, enrollment, and eligibility for benefits. • You must complete, sign, and date this form for it to be valid. A photocopy, fax or electronically scanned and transmitted image is the same as the original. • You can have a signed copy of this form, at your request. • For the proxy to gain access to your Client Portal account, the proxy must activate the account with the code they will be given. The proxy must confirm that they have read and agree to the Northland Counseling Center, Inc. Client Portal Terms and Conditions. These Terms and Conditions apply to each use. • I understand additional medical records may be requested through the Northland Counseling Center, Inc. Medical Records Office. Attestation We attest that we are the individuals identified on this document and we agree to the information outlined above.Attestation I the minor child, agree to allow the adult requesting proxy access to my chart. I understand that information may be requested to confirm person requesting access to safeguard my information.Parent or Guardian must sign form below.
