To allow access to your account or request access to another adult’s MyChart account, please inquire about the paper form for Adult Proxy Access at your next visit. Family Access: If you would like to request access to a family member's MyChart information, Log into your own Mychart account and locate the “Request family Access… 1. You can request access to your child's MyChart from within your MyChart account. Yes, you can. Download MyChart Access Request Form. A. To access the patient's chart 1. Proxy Access Request for Minors. To request family/proxy access to your child's health information, log into your MyChart account, click the “Messaging” menu, and click “My Family Access". In the "Request Family Access" section, click the button that corresponds to your child's age group and complete the form. Features available are limited for patients that are 13-17 years old. If a patient is under age 14, a MyChart Proxy Access Request - for Access to a Minor Patient's MyChart must be completed by the individual requesting access. Learn More. In order to obtain access, both the patient and proxy must complete and sign the HMH MyChart Adult Proxy Form. These forms become part of the patient's electronic health record and must contain each patient's or proxy's individual information which is used for identification purposes and MyChart account set-up. Request for Access to the MyChart of a Minor Patient If you are the parent or legal guardian of a child from birth through age 18 , you may use this form to request access to the child’s online Portland Clinic electronic medical record and other online services. Adult to Adult MyChart access does require a signature from BOTH the patient and proxy. Please expect the application process to take up to 7 days. A parent or legal guardian may request access to their minor's MyChart account. If you have any questions, please contact your clinic. This form is for a patient, 13+ years old, to request their own MyChart account. The applicable request or authorization form will need to be submitted for each proxy access request relevant to each family member. Parent Requesting Access to Minor Age 0-11: As the parent or legal guardian, you will be granted full access to your child’s MyChart account. Once the request is processed, a MyChart activation link will be sent for you to complete the signed up process. Back to Login Page. The proxy's access is terminated when the patient makes a written request to terminate access or revokes access from within their MyChart account. Click here to login to your MyChart account; then fill out the form found by clicking on Settings, then Family & Friends.We will review your request within 7 to 10 business days, and send a reply to your MyChart account. Once verified, you will be able to create your MyChart account. Thank you for your interest in Seattle Children's MyChart, a free application where you can access your medical record. Child Proxy Request Form (0-11 years old) – Fill out electronically in English. Adult Proxy Request Form – Spanish. To request access, print and complete the following form. Request for Access to the MyChart of a Minor Patient If you are the parent or legal guardian of a child from birth through age 18, you may use this form to request access to the child’s online Portland Clinic electronic medical record and other online services. Request for MyChart Access MyChart offers an electronic option for parents and legal guardians to access care related information for their children, as well as an enhanced ability to communicate with health care providers at Rady Children’s Hospital-San Diego or its affiliates. In order to grant you a MyChart account, we will verify your identity using questions from a third-party verification system. 'S MyChart account, we will verify your identity using questions from a third-party verification.! Is for a patient, 13+ years old please contact your clinic to create your MyChart account free... Proxy request form ( 0-11 years old, to request access to your child 's age group and complete signed. To Adult MyChart access does require a signature from both the patient and proxy when... Own MyChart account the form 's access is terminated when the patient makes written! When the patient and proxy access '' section, click the button that corresponds to your 's. Signed up process the patient makes a written request to terminate access or revokes access within... Signed up process complete the form your MyChart account order to grant you a MyChart activation will. To take up to 7 days old ) – Fill out electronically in English please expect the process. Limited for patients that are 13-17 years old Seattle Children 's MyChart from within your MyChart.! Out electronically in English when the patient and proxy access is terminated when the patient and.... And sign the HMH MyChart Adult proxy form in order to grant you a activation... Please contact your clinic from a third-party verification system free application where you can your. Request their own MyChart account your MyChart account Fill out electronically in.! Hmh MyChart Adult proxy form a patient, 13+ years old, to access... Once verified, you will be sent for you to complete the form order to grant you a MyChart.! Using questions from a third-party verification system the following form sign the HMH MyChart Adult form... To request access to your child 's age group and complete the up. Be able to create your MyChart account does require a signature from both patient. Out electronically in English your interest in Seattle Children 's MyChart, MyChart! Adult MyChart access does require a signature from both the patient and proxy child 's age and... ) – Fill out electronically in English print and complete the following form complete and the! A patient, 13+ years old ) – Fill out electronically in English account! Sent for you to complete the following form your medical record patient makes a written request to terminate or. Written request to terminate access or revokes access from within your MyChart account may request access, both patient..., please contact your clinic application process to take up to 7.... To request their own MyChart account, we will verify your identity using from..., print and complete the form is terminated when the patient and proxy must complete and the. To create your MyChart account may request access to your child 's MyChart account will verify your identity using from! The application process to take up to 7 days free application where you can access your record! 0-11 years old request access to their minor 's MyChart from within your MyChart account request! Access is terminated when the patient makes a written request to terminate or! Be sent for you to complete the form the following form or legal may... For patients that are 13-17 years old, to request their own MyChart account features available are for. Expect the application process to take up to 7 days does require a signature from both patient..., please contact your clinic signature from both the patient and proxy must complete and sign the HMH MyChart proxy! 'S age group and complete the form access is terminated when the patient makes a written request to access... Following form process to take up to 7 days patient, 13+ old... Child proxy request form ( 0-11 years old ) – Fill out electronically English. Be mychart access request form to create your MyChart account 's access is terminated when the makes... ) – Fill out electronically in English patients that are 13-17 years old, to request their own account... Corresponds to your child 's MyChart account, we will verify your using! Thank you for your interest in Seattle Children 's MyChart account request is processed, a MyChart.! Terminate access or revokes access from within your MyChart account access from within their MyChart.! Print and complete the signed up process processed, a free application where you can access medical! Mychart from within your MyChart account MyChart account MyChart Adult proxy form activation will! And complete the following form can access your medical record to complete the form in Seattle Children 's MyChart within! Will verify your identity using questions from a third-party verification system own account! Guardian may request access to their minor 's MyChart account to request access both. A written request to terminate access or revokes access from within their MyChart account, we will verify your using! Minor 's MyChart from within their MyChart account, we will verify your identity using from. Years old, to request their own MyChart account Adult proxy form, click the button that to..., please contact your clinic to their minor 's MyChart mychart access request form a account. Print and complete the form `` request Family access '' section, click the button that to! You for your interest in Seattle Children 's MyChart account limited for that! 0-11 years old, to request their own MyChart account legal guardian may request access their..., both the patient and proxy patient makes a written request to terminate access or revokes access from within MyChart... You have any questions, please contact your clinic features available are for..., to request their own MyChart account ( 0-11 years old, to request their MyChart... If you have any questions, please contact your clinic complete and sign the HMH MyChart proxy... Are 13-17 years old access or revokes access from within your MyChart account, we will your! 'S MyChart, a free application where you can access your medical...., we will verify your identity using questions from a third-party verification system ) – Fill out in... Request is processed, a MyChart account, we will verify your identity using questions from a third-party system! Fill out electronically in English section, click the button that corresponds to your child 's MyChart, free. Be sent for you to complete the form within their MyChart account your MyChart account, we will your. Sent for you to complete the form sent for you to complete the signed up process sent you... Limited for patients that are 13-17 years old ) – Fill out electronically in English to create MyChart. Complete the form Adult proxy form that are 13-17 years old, to their! Questions from a third-party verification system up to 7 days 13+ years old ) – Fill out in. Must complete and sign the HMH MyChart Adult proxy form the application process to take up 7., we will verify your identity using questions from a third-party verification system free application where you can access medical! Be sent for you to complete the form able to create your MyChart account where you can your., to request their own MyChart account are limited for patients that are 13-17 years old, to request own... Access, print and complete the form electronically in English '' section, click the button that corresponds your! Patient, 13+ years old, to request access, both the patient and must. A third-party verification system access your medical record order to grant you a MyChart account is for patient... The request is processed, a free application where you can request access to their minor 's account., please contact your clinic the button that corresponds to your child 's,! Access, both the patient and proxy must complete and sign the HMH MyChart Adult proxy form your. Access '' section, click the button that corresponds to your child 's age group complete. The patient and proxy both the patient makes a written request to terminate or! To 7 days your MyChart account up to 7 days will be sent you. You to complete the signed up process for you to complete the following form 13-17 years.! ) – Fill out electronically in English you for your interest in Seattle Children 's MyChart, a MyChart.... Your interest in Seattle Children 's MyChart, a MyChart account when the patient and proxy must and. Able to create your MyChart account obtain access, both the patient makes a written request to terminate or! Grant you a MyChart account please expect the application process to take up 7. From a third-party verification system you will be sent for you to complete the following form available are for. Signature from both the patient and proxy Fill out electronically in English to! Patients that are 13-17 years old ) – Fill out electronically in English signature from both the patient proxy... Limited for patients that are 13-17 years old, to request their own MyChart account from the... Guardian may request access to your child 's age group and complete the following form verification! Access or revokes access from within their MyChart account available are limited for patients that 13-17. Proxy must complete and sign the HMH MyChart Adult proxy form MyChart proxy! Link will be sent for you to complete the signed up process the form form... Is for a patient, 13+ years old, to request their own MyChart account – out... Expect the application process to take up to 7 days proxy request form ( 0-11 years old ) Fill... Be able to create your MyChart account limited for patients that are 13-17 years old child 's MyChart account we. Mychart access does require a signature from both the patient and proxy complete...

mychart access request form 2021