MyChart -

Organization

Parent/Guardian Information

First name

Middle Name

Last Name

Street address

City

State

Zip

Date of birth

Confirm date of birth

SSN (Last four digits)

Confirm SSN

Daytime phone

Email address

Confirm email address

Child 1

First name

Middle name

Last name

MRN

Date of birth

Confirm date of birth

SSN (Last four digits)

Confirm SSN

Relationship to patient

Birth Parent

Legal Guardian

Power of Attorney

Other

Specify relationship

Legal Guardianship papers must be on file before access can be granted.

Child 2

First name

Middle name

Last name

MRN

Date of birth

Confirm date of birth

SSN (Last four digits)

Confirm SSN

Relationship to patient

Birth Parent

Legal Guardian

Power of Attorney

Other

Specify relationship

Legal Guardianship papers must be on file before access can be granted.

Child 3

First name

Middle name

Last name

MRN

Date of birth

Confirm date of birth

SSN (Last four digits)

Confirm SSN

Relationship to patient

Birth Parent

Legal Guardian

Power of Attorney

Other

Specify relationship

Legal Guardianship papers must be on file before access can be granted.

Child 4

First name

Middle name

Last name

MRN

Date of birth

Confirm date of birth

SSN (Last four digits)

Confirm SSN

Relationship to patient

Birth Parent

Legal Guardian

Power of Attorney

Other

Specify relationship

Legal Guardianship papers must be on file before access can be granted.

Additional Patients

If you have more than 4 patients for whom you would like proxy access, please provide each of the additional patient's information in the box below.

After validating your submission with your MyChart membership information your activation code will be emailed to you. Your activation code will allow you to create your MyChart account. Please allow up to one business day for processing and verification. Should we have any questions regarding your submission, we will contact you via the daytime phone number you have submitted.

Child Proxy Access Request