Name: | DOB: | MRN: | PCP:

Request to Access a Minor's Record

Use this form to request MyChart access to a minor's record via MyChart. Enter information about the minor to whom you are requesting access as well as information about yourself. All fields are required.

You must be a parent or authorized legal guardian to be granted access and have your own active MyChart account. You may be asked to provide legal documentation verifying authorization to access this minor's record or to provide other additional information. Please allow up to 48-72 hours (normal business hours) to process your request.

If you need to sign up for a MyChart account please Click Here.

Your Information:

Minor Information:

The person you are requesting MyChart access to.