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MYCHART PROXY ACCESS FORM: CHILD

To sign up for MyChart proxy access for your child’s records, you need to complete this form. You must also have your own MyChart account established for access.

Proxy's Information
Parent/Legal Guardian (“Proxy”) Information: If the Proxy sees providers at the Organizations, the Proxy needs to also complete the Enrollment Form if not already completed.

Proxy Access Request: Adult to Child
My Relationship to the Child/Teen is as follows: Parent OR Permanent Legal Guardian of the Patient – Court Order Appointing Guardian and Letters of Guardianship verifying the Proxy’s status as permanent legal guardian of the patient must already be on file in the patient's chart or must be emailed to sm_mychartproxyforms@confluencehealth.org before proxy can be granted.

Please note the following age range limitations for MyChart:
• If your child is age 0-12, you will be granted full access to his/her MyChart record.
• If your child is age 13-17, you will be granted partial access to his/her MyChart record (e.g., immunizations).
• If you want full access to your Teen’s MyChart account, your teen will need to grant this through their MyChart account.
• Once your child reaches age 18, you will no longer have access to his/her MyChart record.

These limitations do not affect any legal right you have to access your child’s record by other means. To request a paper copy of your child’s record, please contact the Health Information Management Department.

By signing below, I acknowledge and agree that:
• I will be using my own MyChart account at the Organization to access this Child’s MyChart account.
• I will keep my password confidential and not share this information with anyone.
• I must have parental rights and legal guardianship rights to access this child’s record.
• I have not been denied periods of physical placement with the Child and there are no court orders or restraining orders in effect limiting my access to this Child’s medical records and/or information.
• Communications on behalf of the Child through MyChart must be sent from the Child’s record and responses will be received in the Child’s record. MyChart e-mail alerts will be sent to the e-mail address entered under Parent/Legal Guardian (“Proxy”) Information.
• I have completed the MyChart Authorization for Use or Disclosure of Electronic Protected Health Information

Patient Information
Please provide the following information for your child: (NOTE: If you have more than one child for whom you would like MyChart access, please complete additional forms.)