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.