MyChart -

Use this form to request MyChart access to a minor (patients under the age of 16). Enter information about the minor to whom you are requesting access as well as information about yourself. All fields are required except for middle initial fields.

Minor Information:

The person you are requesting MyChart access to.

First Name:

Last Name:

Middle Initial:

Sex:

DOB:

Your Information:

Your First Name:

Your Last Name:

Your Middle Initial:

Your DOB:

Street Address:

City:

State:

ZIP:

Last Five Digits of Your SSN#:

Your Phone:

Your Email:

This minor is your:

If other, please specify:

Right to access:

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

Request to Access a Minor's Record - Public Form

Minor Information:

Your Information: