Name: | DOB: | MRN: | PCP:

MyChart Parent/Guardian Sign Up Form

Please fill out the information requested below to create a parent MyChart login. Then, continue to the Patient Information section to add information about all of your children (up to 5).

To view all health records with one MyChart account, click the "Additional Sibling" links to add information for up to five children. If you have a sixth child (or more) that you would like to add to MyChart, please contact your PediaTrust practice.

If your child is 12 years and older, please remember to submit a signed authorization form to your PediaTrust practice: MyChart Authorization Forms

Please Note: If you are a patient 18 years or older and would like to request access to MyChart, please complete the MyChart Patient Sign Up form.

*These items are required.

Parent/Guardian Information:

xxx-xxx-xxxx

Patient(s) Information:

Note: Click the "Additional Sibling" links to add information for up to five children. If you have six or more children that you would like to add to MyChart, please contact your PediaTrust practice. MM/DD/YYYY
+ Additional Sibling (Optional)

Enter Additional Sibling Information:

MM/DD/YYYY
Enter a different address
+ Additional Sibling (Optional)

Enter Additional Sibling Information:

MM/DD/YYYY
Enter a different address
+ Additional Sibling (Optional)

Enter Additional Sibling Information:

MM/DD/YYYY
Enter a different address
+ Additional Sibling (Optional)

Enter Additional Sibling Information:

MM/DD/YYYY
Enter a different address

I certify that I am the parent or legal guardian of the child listed above and that all information I have provided is correct. I hereby request access to my child's online record. This authorization is valid until it is revoked or otherwise expires.

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
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 access to someone else (parent)
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, please complete the MyChart Patient Sign Up form.