Name: | DOB: | MRN: | PCP:

MyChart Parent/Guardian Sign Up Form

Please provide the information requested below. Up to 3 children are allowed on this form.

To sign up for proxy access to more than 3 children, please fill out and submit this form again.

If your child is 12 years and older, please remember to submit a signed authorization form: 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.

Patient(s) Information:

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
To sign up more than 3 children, please fill out and submit this form again.

Parent/Guardian Information:

xxx-xxx-xxxx

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 for proxy access is required. Please visit the Authorization Form page to fill out the correct forms.