Name: | DOB: | MRN: | GP:

Proxy Access Request

Thank you for your interest in MyGOSH, an easy-to-use internet tool that provides you quick and secure online access to some of your child's health information. To sign up for access to your child's MyGOSH record, please complete and submit the following form for approval. Once your request has been approved, we will email your activation code within 7 business days. We will contact you if we have any questions regarding your information. Please note that access to a child’s record through MyGOSH can only be granted to a Parent or Legal Guardian.

Please note the limitations below for MyGOSH based on your child's age:

A patient's parent or guardian with parental responsibility has sole access to their child's information through MyGOSH as a proxy up until the child is 12 years old;

A patient aged 12-16 years is entitled to access information from MyGOSH if they request this and are deemed to have capacity by their clinician. At the same time the parent or guardian with parental responsibility continues to have proxy access to the patient’s MyGOSH information by default. If the patient aged 12-16 years wishes to remove a proxy from the MyGOSH, the clinician may agree to that request in their absolute discretion;

From 16 years of age, the patient will have direct access to their MyGOSH; Proxy access can be provided with patient consent.

Proxy access will be permitted without patient consent where the patient is aged 16-18 years and has reduced capacity as determined by the clinician. This continues for as long as the young person is a patient at GOSH or turns 18 years of age (whichever occurs first). For more information please refer to Growing up and Gaining Independence.

From 18 years of age, proxy access for a patient without full capacity can only be provided with a Court Order. Information can be found here: www.gov.uk/become-deputy/apply-deputy

If you have any questions, please contact the MyGOSH helpdesk at MyGOSH.Helpdesk@gosh.nhs.uk or 0207 829 7985.


* Indicates a required field

Parent/Legal Guardian's Information
 

Date of birth of the parent or legal guardian.

Requesting access for:
Child's Information
 
Relationship to Child*
 
Additional Child's Information
 
Relationship to Child*
 
Additional Child's Information
 
Relationship to Child*
 
Certification

I certify that I am the patient or legally authorized representative of the patient. By signing this form, I acknowledge that I have read and understand this MyGOSH Request Form and I agree to its terms and conditions. I hereby request access to my child and/or children’s online health record.

Certification*