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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.

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.