Name: | DOB: | MRN: | PCP:

Self-Access Request

Thank you for your interest in Children's Health MyChart, an easy-to-use internet tool that provides you quick and secure online access to some of your health information. To sign up for access to your 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 seven business days. We will contact you if we have any questions regarding your information.

If you are a parent or legal guardian requesting access to a child's record, please complete the Proxy Access Request: Proxy Access Request

Patient's Information
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 online health record.

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