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 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 childís 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 patientís 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 patientís personal representative.
If you are a patient 18 years or older and would like to request access to the online MyChart record of another patient 18 years or older
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.