Name: | DOB: | MRN: | PCP: | Legal Name:

Request to Access a Minor's Record

AgeAccess LevelDefinition
0 - 13Full AccessAll 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 - 17Limited 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 authorizationFull 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 documentationFull 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:

Minor Information:

The person you are requesting MyChart access to.