Online Health Account Forms

Online Health Account Forms

To set up and access a child's or other family member's health records (also called Proxy Access) requires additional authorization forms to be completed. All forms must be returned to your doctor's office before an Online Health Account can be established.

Also note: You will notice the OSF logo on the forms below. The University of Illinois College of Medicine at Peoria has contracted with OSF HealthCare in order to provide you with the UICOMP Online Health Account and access to your health information.

Child Under Age 12 Proxy Form

To request access to your child's Online Health Account, please complete this form. Please note that your child's account will be accessed through your (the Proxy's) account. Completion of this form is required before we can establish an Online Health Account for you and your child. Return the completed form to your healthcare representative.

Child Ages 12-17 Proxy Form

Please visit your University doctor's office for the proper form to request access. This form must be completed and signed at your doctor's office.

Adult Proxy Form

To request access to the Online Health Account of an adult whose medical care or payment of care you manage, please complete both pages of this form. The patient must sign this form and provide authorization on page 2 via the "Adult Proxy Authorization for Access to Medical Information" form. The patient's account will be accessed through your (the Proxy's) Online Health Account. Completion of this form is required before we can establish an online account for you and access to the patient's information. Return forms to your healthcare provider.