mychart access request form


If you have any questions, please contact your clinic. In order to grant you a MyChart account, we will verify your identity using questions from a third-party verification system. 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. The proxy's access is terminated when the patient makes a written request to terminate access or revokes access from within their MyChart account. Thank you for your interest in Seattle Children's MyChart, a free application where you can access your medical record. Please expect the application process to take up to 7 days. 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… Download MyChart Access Request Form. Yes, you can. Once the request is processed, a MyChart activation link will be sent for you to complete the signed up process. 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". A. 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. 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. In order to obtain access, both the patient and proxy must complete and sign the HMH MyChart Adult Proxy Form. In the "Request Family Access" section, click the button that corresponds to your child's age group and complete the form. A parent or legal guardian may request access to their minor's MyChart account. To request access, print and complete the following form. Learn More. This form is for a patient, 13+ years old, to request their own MyChart account. Proxy Access Request for Minors. Adult Proxy Request Form – Spanish. 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. Back to Login Page. To access the patient's chart 1. Adult to Adult MyChart access does require a signature from BOTH the patient and proxy. 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. 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. Child Proxy Request Form (0-11 years old) – Fill out electronically in English. 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. 1. Once verified, you will be able to create your MyChart account. You can request access to your child's MyChart from within your MyChart account. Features available are limited for patients that are 13-17 years old. The applicable request or authorization form will need to be submitted for each proxy access request relevant to each family member. 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