MyChart - Grant Access to My Record

Enter information about the adult to whom you are granting access. All fields are required.

Step 1 | TELL US ABOUT YOU

I am requesting access to a currently admitted patient.

Today's Date:

First Name:

Middle Initial:

Last Name:

Your Date of Birth:

Street Address:

City:

State:

Zip Code:

Mobile Phone (xxx-xxx-xxxx):

Email Address:

First Name:

Last Name:

Sex:

Date of Birth:

Address:

City:

State:

Zip Code:

Email Address:

Phone Number:

This adult is your:

If other, please specify:

Access to grant:

Right to access:

I authorize this/these adult(s) to access my medical information.