Name: | DOB: | MRN: | PCP:

12-17 Year Old Patient MyChart Agreement for Access

To sign up for you and your parent/legal guardian to have access to your MyChart record, please complete the form in its entirety. Completing this form allows access to your protected health information maintained by Erlanger Health System through MyChart.

Acknowledgement
AS THE PATIENT AND A MINOR, I ACKNOWLEDGE AND UNDERSTAND THAT:

  • I agree to allow the parent/legal representative(s) named above to access my medical information in my Erlanger MyChart account. I understand I may revoke this access any time by asking my doctor to do so.
  • I understand my parent/legal representative(s) will lose access automatically when I turn 18 years old.
  • 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 health information. To prevent this, I will not share my username or password with anyone.
  • 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.
  • In order for me to have an MyChart account, I must allow at least one parent/legal representative to have access to my MyChart account. This means, my parent/legal representative will see all information in my MyChart account.
  • I will not use MyChart in an emergency. In case of medical emergency, I should call 911.
  • I understand that MyChart contains selected, and in some circumstances 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.

Patient Information:

This section should be completed by the minor who is having Proxy access requested and wanting their own MyChart Account.

Parent/Guardian Information:

This section should be completed by the minor who is having Proxy access requested and wanting their own MyChart Account. Please provide the Parent/Guardian requesting Proxy Access to your account.

Agreement and Acknowledgement Statement:

Agreement/Acknowledgement: