MyChart Parent/Guardian Sign Up Form

Please Note: The below form is for requesting enhanced access to a child patient ages 0-11, or standard access for teen patients ages 12-17. If you are requesting enhanced access to a teen please instead complete the appropriate form here: MyChart Authorization Forms

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.

*These items are required.

Patient(s) Information:

MM/DD/YYYY
Additional Sibling (Optional)
Enter Additional Sibling Information:
MM/DD/YYYY
Enter a different address (if applicable):
Additional Sibling (Optional)
Enter Additional Sibling Information:
MM/DD/YYYY
Enter a different address (if applicable):
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 MyChart Authorization Forms page to fill out the correct forms.

 

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