Name: | DOB: | MRN: | PCP:

MyChart Activation Code Request

Thank you for your interest in MyChart. To sign up, please complete this form. We will email your activation code within seven business days. We will contact you if we have any questions. A confirmation letter will also be sent to your address on file.

Please note some age limitations for MyChart accounts:

  • If your child is 14-17, both you and your child will need to print, sign and return the MyChart Consent form.
  • Once your child turns 18, you will not have access to your child’s MyChart account. Your child may fill out an Adult Accessing Adult form for parental access.

Parent/guardian information

Child information

Relationship:

If you are the legal guardian, we must have guardianship papers on file before access can be granted.


Additional child information

Relationship:

If you are the legal guardian, we must have guardianship papers on file before access can be granted.


Additional child information

Relationship:

If you are the legal guardian, we must have guardianship papers on file before access can be granted.


Please read and certify

I certify that I am the parent or legal guardian of the child/children listed above, the information that I have provided is accurate and I have the legal right to view this health care information. I agree to abide by the terms and conditions of MyChart. I hereby request access to my child/children’s online health record.

Agree
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