MyChart -

To request proxy access, please complete the form below. We will contact you by phone or email if we have any questions regarding the information provided.

Step 1 | TELL US ABOUT YOU

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:

Step 2 | CHILD/PATIENT INFORMATION:

Patient's First Name:

Patient's Middle Initial:

Patient's Last Name:

Sex Assigned at Birth:

Patient's Date of Birth:

Your relationship to the child:

If other, please specify:

ADDITIONAL CHILD/PATIENT INFORMATION:

Patient's First Name:

Patient's Middle Initial:

Patient's Last Name:

Sex Assigned at Birth:

Patient's Date of Birth:

Your relationship to the child:

If other, please specify:

ADDITIONAL CHILD/PATIENT INFORMATION:

Patient's First Name:

Patient's Middle Initial:

Patient's Last Name:

Sex Assigned at Birth:

Patient's Date of Birth:

Your relationship to the child:

If other, please specify:

CERTIFICATION:

I certify that I have the legal right to this/these minor's medical information.

MyChart Activation Code Request: New Proxy Account

Step 1 | TELL US ABOUT YOU

Step 2 | CHILD/PATIENT INFORMATION:

ADDITIONAL CHILD/PATIENT INFORMATION:

ADDITIONAL CHILD/PATIENT INFORMATION:

CERTIFICATION: