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MyChart ® Epic Systems Corporation

Request Family Access to a Minor Patient

Use this form to request access to a minor patient's MyChart account. Once a child turns 18 access is automatically revoked. You must be the child's parent or legal guardian to access the record.


Parent or Legal Guardian Information

 
First Name*
 
Last Name*
 
Date of Birth*
 
Address*
 
City*
 
State*
 
Zip*
 
Home Phone*
(xxx-xxx-xxxx)
 
Email*

Child Information

 
First Name*
 
Last Name*
 
Date of Birth*
 
Child's Primary Doctor*
 
Patient's Insurance*
 
Address*
Same as above Different
 


* 
I certify that I am the parent or legal guardian of the child or children listed here. I hereby request access to my child's electronic medical record.
 
 

* Required fields