MyChart -

Age	Access Level	Definition
0 - 13	Full Access	All access to the patient's MyChart is permitted through Mychart Proxy Access. Please fill out the form below to request Proxy Access to a minor's account. Your request will be reviewed and the appropriate consent form will be sent to you.
14 - 17	Limited Access by Default (with option for Full Access)	At age 14 a parent/guardian with existing Proxy Access is automatically changed to Limited Access. Limited Access displays a patient's Allergies, Immunizations, as well as the ability to electronically schedule appointments. A consent form will be required to obtain Proxy Access. At the discretion of the treating provider, in conversation with the patient as well as the parent/guardian, the Limited Access can be changed to Full Access. At the age of 18, all access to the patient's MyChart (whether Limited or Full) automatically expires.
18+	Full Access with proper authorization	Full Access to the patient's MyChart for a family member is permitted with an invitation from the patient and acceptance of the Terms and Conditions.
Legal Guardianship - 18+	Full Access with proper documentation	Full Access to the patient's MyChart is permitted upon request.

Use this form to request MyChart access to a minor. Enter information about the minor to whom you are requesting access as well as information about yourself. All fields are required.

Your Information:

First Name:

Last Name:

Date of Birth:

Legal Sex:

Phone:

Street Address:

City:

State:

ZIP:

Email:

Minor Information:

The person you are requesting MyChart access to.

First Name:

Last Name:

Legal Sex:

Date of Birth:

Minor's Relationship to You:

If other, please specify:

I certify that I have the legal right to this minor's medical information.

Request to Access a Minor's Record

Your Information:

Minor Information: