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MyChart Authorization Forms

If your child is 12 years and older, a signed authorization form may also be required.

If you are a parent of a patient 0-11 years old
No signed authorization form is required.

If you are a parent of a patient 12-17 years old
Because your child's record may contain certain types of medical information protected under state and federal law, a parent or legal guardian may access the online MyChart record of a patient 12-17 years old only with the patient's consent.

Please print, sign and submit via fax or mail the Parent/Guardian Access form. Both the child aged 12-17 and the parent/legal guardian must sign the form.

If a patient who is over 12 years is incapable of signing
Please print, sign and submit via fax or mail the Guardian/Power of Attorney form.

If you are a Guardian/Power of Attorney of a patient over age 12 a signed authorization is required
Please print, sign and submit via fax or mail the Guardian/Power of Attorney form. Request must be accompanied by a copy of the legal documentation verifying the authority of the patient's personal representative.

If you are a patient 18 years or older and would like to grant someone else (parent) access to your MyChart
A signed authorization form is required. Please print, sign and submit by mail or fax: Adult Proxy Access form.

Note: If you are a patient 18 or over and signing up for yourself, no authorization form is required.

Please send the completed form via postal mail or fax to your child's primary practice location:

Ann & Robert H. Lurie
Children's Hospital of Chicago

Health Information Management
225 E Chicago Ave, Box 11
Chicago, IL 60611
Fax: 312-227-9733

Bedingfield and Rosewell Pediatric Office

2500 W Higgins Rd, Suite 440
Hoffman Estates, IL 60169
Fax: 847-839-0800

Chicago Area Pediatrics
(Traisman, Benuck, Merens & Kimball)

1950 Dempster St
Evanston, IL 60202
Fax: 847-869-4330

Child and Adolescent Health Associates

1030 N. Clark St, Suite 400
Chicago, IL 60610
Fax: 312-943-6924

Children's Healthcare Associates

2835 N. Sheffield Ave, Suite 501
Chicago, IL 60657
Fax: 773-348-7163

1535 Lake Cook Rd, Suite 101
Northbrook, IL 60062
Fax: 847-480-1510

Errol Baptist, MD

461 North Mulford Rd, Suite 4
Rockford, IL 61107
Fax: 815-397-1879

Lakeview Pediatrics

1525 W Belmont Ave, Suite 103
Chicago, IL 60657
Fax: 773-472-7395

Milestone Pediatrics

4043 S Route 59
Naperville, IL 60564
Fax: 630-420-8957

Northwestern Children's Practice

680 N Lake Shore Dr, Suite 1050
Chicago, IL 60611
Fax: 312-642-0753

Oak Park Pediatrics

1107 Chicago Ave
Oak Park, IL 60302
Fax: 708-383-2969

Pediatric Associates of the North Shore

1144 Wilmette Ave
Wilmette, IL 60091
Fax: 847-256-6482

Pedios, Ltd.

260 Chicago Ave
Oak Park, IL 60302
Fax: 708-383-0811

Rappaport Pediatrics, S.C.

570 Lincoln Ave, Suite 1
Winnetka, IL 60093
Fax: 224-255-6709

Streeterville Pediatrics

233 E Erie St, Suite 304
Chicago, IL 60611
Fax: 312-280-1485

Town & Country Pediatrics

Lurie Children's Health Information Management
225 E. Chicago Ave, Box 11
Chicago, IL 60611
Fax: 312-227-9733
If you are a parent of a patient 0-11 years old
No signed authorization form is required.

If you are a parent of a patient 12-17 years old
Because your child's record may contain certain types of medical information protected under state and federal law, a parent or legal guardian may access the online MyChart record of a patient 12-17 years old only with the patient's consent.

Please print, sign and submit via fax or mail the Parent/Guardian Access form. Both the child aged 12-17 and the parent/legal guardian must sign the form.

If a patient who is over 12 years is incapable of signing
Please print, sign and submit via fax or mail the Guardian/Power of Attorney form.

If you are a Guardian/Power of Attorney of a patient over age 12 a signed authorization is required
Please print, sign and submit via fax or mail the Guardian/Power of Attorney form. Request must be accompanied by a copy of the legal documentation verifying the authority of the patient's personal representative.

If you are a patient 18 years or older and would like to grant someone else (parent) access to your MyChart
A signed authorization form is required. Please print, sign and submit by mail or fax: Adult Proxy Access form.

Note: If you are a patient 18 or over and signing up for yourself, no authorization form is required.

Please send the completed form via postal mail or fax to your child's primary practice location:

Elm Street Pediatrics

572 Lincoln Ave, Suite 3
Winnetka, IL 60093
Fax: 847-501-4075

Fairview Pediatrics

1475 E Belvidere Rd, Suite 215
Grayslake, IL 60030
Fax: 847-548-8899

Highland Park Pediatric Associates

1160 Park Ave West, Suite 3E
Highland Park, IL 60035
Fax: 847-432-9480

Lake Shore Pediatrics

900 N. Westmoreland Rd, Suite 106
Lake Forest, IL 60045
Fax: 847-615-0730

27790 W. Hwy 22, Suite 36
Barrington, IL 60010
Fax: 847-381-4602

1800 Hollister Dr, Suite 220
Libertyville, IL 60048
Fax: 847-362-4615

Pediatric Associates of Arlington Heights

880 West Central Rd, Suite 4200
Arlington Heights, IL 60005
Fax: 847-259-5322

765 Ela Rd, Suite 102
Lake Zurich, IL 60047
Fax: 847-726-7657

Pediatric Associates of Barrington

912 W. Northwest Hwy, Suite G-7
Fox River Grove, IL 60021
Fax: 847-381-6828

260 Congress Pkwy, Suite B
Crystal Lake, IL 60014
Fax: 815-459-1648

Pediatric Partners

300 Center Dr, Suite 103
Vernon Hills, IL 60061
Fax: 847-362-4425

767 Park Ave West, Suite 230
Highland Park, IL 60035
Fax: 847-681-7110

Premier Pediatrics

185 N Milwaukee Ave, Suite 220
Lincolnshire, IL 60069
Fax: 847-821-9501

36100 Brookside Dr, Suite 204
Gurnee, IL 60031
Fax: 847-821-9501

Woodfield Pediatrics

1345 Wiley Rd, Suite 117
Schaumburg, IL 60173
Fax: 847-884-1113