HealthCare Surrogate Form for a Minor
Who Can Be a Health Care Surrogate?
A health care surrogate is a trusted adult, such as a family member or family friend, who you authorize to make health care decisions for your child when you are not available. The person you designate as your child’s health care surrogate must be at least 18 years old.
Before Your Child’s Appointment
Complete the Designation of Health Care Surrogate for a Minor form.
Please:
- Complete all required information on the form.
- Sign the form in the presence of two adult witnesses. The person you designate as the health care surrogate cannot serve as one of the witnesses.
- Print the completed form.
- Give the form to the adult bringing your child to the appointment.
Download, Sign and Bring the Surrogate Form to the Appointment
- Health Care Surrogate Form for a Minor
Download Surrogate Form – English - Designación de un Sustituto Para Atención Médica de un Menor
Descargar el Formulario – Español
If the surrogate should remain authorized after this appointment, enter an expiration date on the form.
This Form Does Not Provide Access to Your Child’s Medical Records
The Health Care Surrogate Form for a Minor allows you to designate another trusted adult to accompany your child to a medical appointment and make health care decisions when you are not available.
Completing this form does not give that person proxy access to your child’s medical records or MyChart account. Proxy access to your child’s MyChart account or medical records is a separate process and requires additional authorization.
Questions or Changes to a Health Care Surrogate
If you have questions about the Health Care Surrogate Form for a Minor, or if you need to remove a health care surrogate you previously designated, please call 954-265-0150.