Name: | DOB: | MRN: | PCP:

Request Proxy Access for Child 12 to 17 Years of Age

To sign up for access to your child's MyChart record, please complete the form in its entirety. Completing this form allows access to portions of the patient's protected health information maintained by Erlanger Health System through MyChart.

Acknowledgement
I ACKNOWLEDGE AND AGREE THAT:

  • I have parental rights or legal guardianship rights to access this patient's record.
  • I have not been denied periods of physical placement with the patient and there are no court orders or restraining orders in effect limiting my access to this patient's medical records and/or information.
  • I understand that MyChart is intended as a secure online source of confidential medical information. If I share my MyChart ID and password with another person, that person may be able to view my or my child's health information.
  • I agree that it is my responsibility to select a confidential password, to maintain my password in a secure manner, and to change my password if I believe it may have been compromised in any way.
  • I will comply with the terms and conditions on the MyChart web site and this document.
  • I agree that access to the patient's information will be terminated when the patient reaches 18 years of age(per the terms and conditions of the MyChart portal). My child will have to agree to the access by completing the "12-17 Year Old Patient MyChart Agreement" form, in addition to me submitting this form, in order to gain full access within MyChart. If the patient in the 12-17 age group does not submit/sign their agreement, I will receive or maintain limited access to the patient's MyChart.
  • I understand that MyChart contains selected, limited medical information from the patient's medical record and that MyChart does not reflect the complete contents of the medical record. I also understand that a paper copy of a patient's medical record may be requested.

Parent/Guardian Information

This section should be completed by the individual requesting access to a minor's MyChart record.

Child Information

Please provide the following information for your child:
Child 1
Child 2
Child 3

Agreement and Acknowledgement Statement:

Agreement/Acknowledgement: