Name: | DOB: | MRN: | PCP:

Request to Access a Minor's Record

Enter information about the minor to whom you are requesting access. All fields are required.

If you already have a MyChart account, login in to request access to your proxy under the "Share My Record" link in the Health Tab.

For children 12 years of age and older, please print out this proxy request form and return it back to your provider's office.

Minor you are requesting access to:

Additional information for verification:

We need your Social Security for verifying your information.

You can input either your mobile or home phone number.