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Click ‘Get Form’ to open the Sanford Proxy Form in the editor.
Begin by filling out the 'About the Patient/Member' section. Clearly print your name, date of birth, last four digits of your Social Security Number, email, phone number, and Member ID Number if applicable.
Next, complete the 'About the Proxy' section for the individual you are granting access. Again, ensure all fields are filled out clearly including their name, date of birth, last four digits of their Social Security Number, email, street address, city, state, zip code, phone number, and Member ID Number if applicable.
Review the consent statements carefully. By signing this form, you grant your Proxy access to your complete medical records and authorize them to perform specific actions on your behalf.
Sign and date the form at the bottom. If mailing a notarized copy, ensure a notary witnesses your signature.
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Proxy forms must be in writing, and they must be signed and dated by the record owners and their attorneys; otherwise, the vote is invalid. The term of the proxy is 10 months from the date of issuance. Stakeholders or unit owners may use multiple proxies, but the latest one is the only valid one.
What is a child proxy form?
A proxy is an agreed replacement for a voting person. The template form ensures a proxy votes according to the person they represent, not according to their own discretion. It also ensures that only members or proxies vote, rather than unannounced outsiders.
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