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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?

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 the following terms and conditions:

Agreement for Terms and Conditions of Use
Internet Legal Page/Disclaimer for Children's Health MyChart Website
This site (the "Site") is an on-line information and communication service center and internet site provided by Children's Health ("Site Owner"). Access and use of the Site is subject to the following terms and conditions (the "Terms and Conditions") and all applicable laws. By accessing or using the Site, you agree to be bound by all of the terms and conditions of Use of this Agreement. This Agreement is intended to be fully effective and binding. BY USING THE SITE, YOU ACCEPT THESE TERMS AND CONDITIONS OF USE.

The contents of the Site, including text, images, graphics, sound files, animation files, audio and video files and their arrangement on this and other Site Owner’s websites are subject to copyright and intellectual property protection. These contents may not be used for public or commercial purposes without Site Owner’s written permission. Material from the Site may be downloaded for non-commercial and personal use only. Any downloads must retain all copyright and other proprietary notices contained on the materials and may not be altered in any way.

Terms and Conditions
1. General Terms of Use.
• The Site is provided to you for your personal use only and to provide information, education, and communication.
• Site Owner makes no warranties, either express or implied, regarding the contents of the Site.
• This Agreement constitutes your acknowledgement that your sole and exclusive remedy for your dissatisfaction with the Site is to discontinue using the Site.

2. Disclaimers.
• The Site does not constitute an attempt to practice medicine.
• Use of the Site does not establish a doctor-patient relationship.
• Always seek the advice of your physician or other qualified healthcare professional with any questions you may have regarding medical symptoms or a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this Site.
• If you think you have a medical or psychiatric emergency, call 911 or go to the nearest hospital.
• While the Site attempts to remain current, healthcare information changes rapidly and thus the Site should not be relied upon as comprehensive or error-free resource.
• Site Owner may revise the information on this Site or otherwise change or update the Site, including these Terms and Conditions, without notice to you. Site Owner encourages you to periodically read these Terms and Conditions to see if there have been any changes that may affect User.
• Your continued use of the Site will signify your continued agreement to these Terms and Conditions as they may be revised.
• Site Owner reserves the right to revoke access to social media sites and any non-public portions of the Site at any time for any reason.

3. Privacy Policy.
• Site Owner is strongly committed to protecting the privacy of its patients. The Site does not collect personally identifiable information about individuals, except when it is knowingly provided by such individuals.
• Site Owner’s server collects information automatically. The information collected does not link to your personal identity. We view the information collectively to evaluate trends. Information collected includes the browser and version you access the internet through (for example Internet Explorer, Firefox or Google Chrome), the day and time you access the Site, if you are a repeat visitor of the Site or a new visitor, and the pages you visit.
• Any personal information you submit to the Site is governed by Site Owner’s Notice of Privacy Practices. This includes information on your rights to see and receive copies of your personal health information.
• The Notice of Privacy Practice, found here, is in compliance with HIPAA and all other relevant federal and state statutes.

4. Contents/Availability of Site.
• Content on this Site, including text, graphics, logos, button icons, photos, images, forms, audio, video, questionnaires, and software, is the property of Site Owner or its licensors and is protected by United States and international copyright laws. This material may not be used except as provided (a) in these Terms and Conditions or (b) in the relevant text on the Site, as applicable.
• Site Owner neither warrants nor represents that your use of the materials displayed on the Site will not infringe rights of third parties. While Site Owner uses reasonable efforts to include accurate information on the Site, (which is updated periodically), Site Owner makes no warranties or representations as to its accuracy, and you may use it at your own risk.
• The Site may also contain information posted by others, where Site Owner does not have any control. Site Owner assumes no liability or responsibility for any errors or omissions in the content on the Site.
• Site Owner may change the contents of the Site, restrict access to the Site, or terminate the Site at any time.
• Any rights not expressly granted by these Terms and Conditions or any applicable end-user license agreements are reserved by Site Owner. Content and features are subject to change or termination without notice in the editorial discretion of Site Owner.
• The Digital Millennium Copyright Act of 1998 (the "DMCA") provides recourse for copyright owners who believe that material appearing on the Internet infringes their rights under U.S. copyright law. If you believe in good faith that materials appearing on this Site infringe your copyright, you (or your agent) may send us a notice requesting that the material be removed, or access to it blocked.

5. My Chart
• My Chart/Patient Portal is a secure Site provided by Site Owner through which an adult or a minor patient or the patient’s family can obtain limited patient medical information. Although My Chart displays certain information from a patient’s medical record, it DOES NOT display all information from a patient’s medical record.
• To request a complete copy of the patient’s medical record, please contact Site Owner’s Health Information Management Department here; Dallas: 214-456-2503, Plano: 469-303-2509
• Site Owner affords the same degree of confidentiality to health information stored on My Chart as is given to health information stored by Site Owner in any other medium. Firewalls, passwords, encryption, and audit trails are used to safeguard your information. Site Owner has taken steps to make all information received from our online visitors as secure as possible against unauthorized access and use.
• User names and passwords provide two layers of authentication and are stored in an encrypted database that is isolated from the Internet. As a My Chart user, your role in maintaining the security of the patient’s medical information is: 1) changing your password on a regular basis, and 2) keeping your login ID and password confidential.
• Users of My Chart may be notified via email, text or instant message when there is new medical information to be viewed. This means that any person with access to your email, text or instant messages will be able to see this notification. Although no private medical information will be sent via email, text or instant message, the notification will state that new medical information is available by accessing the Patient Portal. You should take this into account when providing Children's Health with any messaging address.
• For any inquiries submitted through the Patient Portal via email, please allow at least three (3) business days for a response.
• Emergency or urgent situations requiring immediate attention SHOULD NOT be submitted electronically, but User should instead call the patient’s doctor, immediately go to the nearest Hospital Emergency Department, or call 911.
• Site Owner is only able to respond to electronic communications based on the information provided by you or the patient. Insufficient information provided could limit medical providers from providing accurate and reliable services.
• You are responsible for checking any responses sent to the My Chart inbox. These messages may contain information important to patient’s health and medical care. 6. Minor Eligibility.
• My Chart/Patient Portal Eligibility: Unless otherwise allowed by law, an individual must be age 18 years or older to request a My Chart account. However, a minor 13 years or older may create a My Chart account with parental/legal guardian permission and that parent/legal guardian being assigned Proxy Access by which parents/legal guardians may access a minor patient’s account. In such circumstance:
••1. A My Chart account will be activated for both the proxy and the account holder.
••2. Only one person will be granted Proxy access to a My Chart account.

• If the proxy’s legal relationship with the account holder changes, the proxy must inform the medical practice immediately by calling Member Services at 844-600-2170, or sending written notice to Children's Health, 1935 Medical District Drive, Dallas, Texas 75235. Due to restrictions imposed by state or federal law, there may be circumstances where the parent or legal guardian cannot be allowed full Proxy Access to a patient’s information on the My Chart/Patient Portal without the minor patient’s consent. Because of these legal requirements, Site Owner reserves the right to deny or limit access as appropriate under the law.
• The individual requesting Proxy Access may be required to provide documentation of his/her authority before any account is activated and access is granted.

7. Proprietary Rights.
Images of people or places displayed on the Site are either the property of Site Owner or third parties. The use of these images by you, or anyone authorized by you, is prohibited unless specifically permitted by these Terms and Conditions or specific permission is provided by Site Owner. Any unauthorized use of these images may violate copyright laws, trademark laws, the laws of privacy and publicity, and communications regulations and statutes. The trademarks, logos, and service marks (collectively the "Trademarks") displayed on the Site are registered and unregistered Trademarks of Site Owner and others. No Trademark displayed on the Site may be used without the written permission of the party that may own the Trademarks displayed on the Site. Your misuse of the Trademarks displayed on the Site, or any other content on the Site, is strictly prohibited. You are also advised that Site Owner will aggressively enforce its intellectual property rights to the fullest extent of the law, including the seeking of criminal prosecution where authorized.

8. External Links.
The Site may contain links to other websites that are not owned or controlled by Site Owner ("Third Party Websites"). Site Owner is not responsible for the content, security or the privacy practices of Third Party Websites. Please review the privacy statement and any terms of use of each Third Party Website you visit. Unless we specifically advise you otherwise, links to Third Party Websites do not constitute or imply endorsement by Site Owner of those sites, the information they contain or any products or services they describe. Site Owner does not receive payment or other remuneration in exchange for linking to or using any Third Party Websites. Your linking to any other off-site pages or other sites is at your own risk.

9. Limitations on Warranties, Liability and Damages.
Your use and browsing of the Site is at your risk. Neither Site Owner nor any other party involved in creating, producing, or delivering the Site is liable for any direct, incidental, consequential, indirect, or punitive damages arising out of your access to, or use of, the Site. Without limiting the foregoing, everything on the Site is provided to you "AS IS" WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESSED OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OR MERCHANT ABILITY, FITNESS FOR A PARTICULAR PURPOSE, AND NON-INFRINGEMENT. Please note that some jurisdictions may not allow the exclusion of implied warranties, so some of the above exclusions may not apply to you. Check your local laws for any restrictions or limitations regarding the exclusion of implied warranties. Site Owner also assumes no responsibility, and cannot be liable for any damages to, or viruses that may infect, your computer equipment or other property on account of your access to, use of, or browsing in the Site, or your downloading of any materials, data, text, images, video, or audio from the Site.

10. Lack of Confidentiality.
Any communication or material that you transmit to the Site by electronic mail or otherwise, including any data, questions, comments, or suggestions, will be treated as non-confidential and non-proprietary, except for information submitted to My Chart/Patient Portal which is subject to Site Owner’s Privacy Practices. Anything that you transmit or post may be used by Site Owner, its affiliates and others providing services for the Site, for any purpose, including reproduction, disclosure, transmission, publication, broadcast, posting and market research. Furthermore, Site Owner and those providing the services for the Site are free to use any ideas, concepts, know-how, and techniques contained in any communication you send to the Site for any purpose whatsoever, including but not limited to developing, manufacturing, and marketing products using such information.

11. Availability of Product.
Since the Site may be accessed from sources internationally where Site Owner does not do business, Site Owner does not represent that it is doing business in all such areas, or that its products or services will be available in any particular country or jurisdiction. Such products or services will only be made available when Site Owner makes them available, and in compliance with applicable laws.

12. Physician Contribution.

13. Social Media Disclaimer.
The opinions and/or views expressed on Site Owner’s social media platforms, including, but not limited to, Children's Health’s blogs, widgets, Facebook, Twitter, LinkedIn and YouTube pages, represent the thoughts of individual contributors and online communities, and not those necessarily of Site Owner or any of its corporate affiliates or any of their respective directors, officers, employees, medical staff or members of its respective board of directors. The opinions and views expressed on these pages do not in any way reflect the views of the Site they are posted on, other sites affiliated with the Site, the staff involved with maintaining the Site or any members of the Site.
• By submitting content (comments, stories, photos, etc.) to any of Site Owners social media sites, you understand and acknowledge that this information is available to the public, and that Site Owner may use this information for internal and external promotional purposes and fundraising purposes. Please note that other participants may use your posted information beyond the control of Site Owner.

14. Security; Risks of Using Secure Sites and Secure Messaging
Children's Health uses encryption technology and takes other precautions to ensure that the information contained or transmitted via MyChart is as secure as reasonably possible from unauthorized use or access. As such, your browser must be enabled to transmit via Secure Socket Layer (SSL) protocol and 128-bit encryption. If your browser currently does not support this protocol, you will see a prompt asking you to update your security and a link to a site where you may obtain the necessary plug-in at no charge. SSL is used for transmitting personal demographic information, personal health information and credit card information. Children's Health is using industry-standard encryption technologies to protect and secure the MyChart site, including the secure messaging function. Because of the added security of web-based, encrypted messaging, Children's Health strongly recommends the use of secure messaging via MyChart, instead of e-mail, for online communications.
However, please note that while Children's Health takes measures to safeguard your security, we cannot guarantee absolute security of the system against inadvertent disclosure or intentional intrusion. The use of electronic communication systems such as the World Wide Web (including secure messaging) for communications has a number of risks that users should consider before use. Such risks include, but are not limited to, the following:
• Electronic communications can be copied, circulated, forwarded and stored, in numerous paper and electronic files. Electronic communications can be accidentally broadcast worldwide and received by many unintended recipients. Backup copies of electronic communications may exist even after the originator or recipient has deleted his or her own copy. Employers and online services have a right to archive and inspect e-mails transmitted through their systems.
• Message senders can misaddress a message. Messages can be intercepted, altered, forwarded, or used without written permission or detection. E-mail notifications can be used to introduce viruses into computer systems. Electronic communications may not be answered in the time frame expected by the parties or they can be misinterpreted.
• Electronic communications are discoverable and can be used as evidence in court.
• Passwords providing access to electronic communications can be stolen and misused, or host systems can be compromised, leading to unauthorized disclosures of personal information.
As a result of these risks, Children's Health cannot guarantee the security and confidentiality of secure messaging and other communication submitted through MyChart, and will not be liable for improper disclosure of confidential information. YOU HEREBY EXPRESSLY ASSUME THE FOLLOWING RISKS, INCLUDING BUT NOT LIMITED TO INTENTIONAL INTRUSION, UNAUTHORIZED DISCLOSURE, FAILURE, DELAY, INTERRUPTION OR CORRUPTION OF DATA OR OTHER INFORMATION TRANSMITTED IN CONNECTION WITH THE USE OF THIS SERVICE.

15. Account Deactivation
An account may be deemed abandoned and expired if the account has no activity for two calendar years. To maintain an active status on your account, then it is your responsibility to periodically login. Should your account be expired, you must re-register.

I hereby request access to my child's and/or children’s online health record.

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