Name: | DOB: | MRN: | PCP:

Proxy Access Request

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

Please note the limitations below for Children's Health MyChart based on your child's age. These age limitations do not affect any legal right you have to access your child's records by other means. To request a paper copy of your child's records, contact the provider's office directly.

If your child is 17 years old or younger, you will be granted full access to their Children's Health MyChart record.

Once your child reaches age 14, they will be able to access their own Children's Health MyChart record pending the approval of the parent/guardian and the provider.

Once your child reaches age 18, you will no longer have access to their Children's Health MyChart record.

If you are a patient over the age of 18 requesting access to your own record, please complete the Self-Access Request: Self-Access Request

Parent/Legal Guardian's Information

Date of birth of the parent or legal guardian.

Requesting access for:
Child's Information
Relationship to Child*
Are you the guarantor for this patient?
Additional Child's Information
Relationship to Child*
Are you the guarantor for this patient?
Additional Child's Information
Relationship to Child*
Are you the guarantor for this patient?
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 Children’s Health MyChart Request Form and I agree to its terms and conditions. I hereby request access to my child's and/or children’s online health record.

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If you have any questions, please contact the Health Information Management office at 214-456-2503.