PCHMyChartAdolescentProxyForm

MyChart® Adolescent Proxy Form

This form used for: Patients 13 to 17 years + 364 days

Requirements for accessing full proxy access to adolescent’s record:

Parent, guardian, or custodian of the patient
Complete and signed MyChart Adolescent Proxy Form by BOTH patient and guardian.
Each parent or individual requesting access must have their own MyChart account

Proxy Information: (All sections required)

Proxy Name*

First Name

Middle Name (optional)

Last Name

Proxy Social Security Number*

Proxy Date of Birth*

Proxy Email Address*

Proxy Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Proxy Phone Number*

Relationship to Patient*

Primary Clinic*

I am requesting Proxy access to the MyChart Record(s) of the individual(s) aged 12-17 who is named below (“Adolescent”) as the parent, guardian, or custodian of the Adolescent. I acknowledge that certain federal and state laws permit my Adolescent to make certain health care decisions on their own behalf, and as such, I will be granted Proxy Access to my Adolescent’s MyChart record only if my Adolescent consents to such access. In Accessing or otherwise communicating through MyChart, I agree to abide by the guidelines for the MyChart Patient Portal electronic sensitive communication. I understand that if the individual(s) for whom I have proxy access requires immediate or urgent care, I am to contact 911 or the individual’s health care provider directly (NOT through MyChart). My failure to adhere to the following guidelines may result in limitation of functionality in MyChart. I agree to never use MyChart to communicate information related to the Adolescent’s substance use disorder, if any. I understand that this Proxy Access Form will expire upon the individual’s 18th birthday and that at that time the individual will have to consent to my access through the Adult Proxy Form. I understand that the individual can revoke my access to records for certain services to which they may independently consent too at any time.

Please provide the following information for the Adolescent whose MyChart® record you are requesting to access. Separate forms must be submitted for each additional name if necessary.

Patient Information: (All sections required)

Patient Name*

First Name

Middle Name (optional)

Last Name

Patient Social Security Number*

Patient Date of Birth*

Patient Email Address*

Patient Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Patient Phone Number*

Physician/Provider to release the record*

Purpose of the release*

Description of the information to be released*

The date, event, or condition on which the consent will expire if not revoked*

By signing below, I acknowledge that I have read, understand, and agree to the MyChart Terms and Conditions. A copy of the MyChart Terms and Conditions can be requested at your physician’s office.

Signature of Patient (Adolescent)*

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Use your mouse or finger to draw your signature above

Patient Date*

Signature of Parent/Guardian*

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Use your mouse or finger to draw your signature above

Parent/Guardian Date*