To sign up for access to your child’s MyChart, please complete and sign this Child Proxy Form and return it to the address shown below. If you are an Everett Clinic patient you will need to have an active MyChart account in order to access your child’s MyChart. If you are not a patient at The Everett Clinic, we will set up an account for you once this form has been processed.
Return all forms to: The Everett Clinic or Fax: (425) 339-5439 Medical Records – Release of Information 3901 Hoyt Avenue
Everett, WA 98201
Parent/Guardian Information: (Completion of all sections is required -- please print clearly)
Name (last, first, middle initial): __________________________________________________________
Date of Birth: ____________________
Street Address: _______________________City: ___________State:_____________ Zip:___________
E-mail Address: ____________________________ Phone Number: ____________________________
Please note the following age range limitations for MyChart. These age range limitations do not affect any
legal right you have to access your child’s record by other means. To request a copy of your child’s record in paper or electronic format, contact the Health Information (Medical Record) Department at The Everett Clinic.
•If your child is age 0-12: You will be granted access to your child’s MyChart.
•Once your child reaches age 13, you will have limited access to your child’s MyChart (see below).
The following information is needed for proxy access: (All fields are required. A form must be provided for each child.
If you need additional forms, request another proxy access form from the Health Information (Medical Record) Department or print one from www.everettclinic.com/MyChart).
Name (last, first, middle initial): __________________________________________________________________
Date of Birth: ________________________
MyChart Terms and Agreement
•I understand that MyChart is intended as a secure online portal for viewing confidential medical information.
If I share MyChart ID and password with another person, that person may be able to view my or my child’s health information, and health information about someone who has authorized me as a MyChart proxy.
•I agree that it is my responsibility to select a confidential password, to maintain my password in a secure manner, and to change my password if I believe it may have been compromised in any way. I understand that MyChart contains selected, limited medical information from a patient’s medical record and that MyChart does not reflect the complete contents of the medical record. I also understand that a copy of a patient’s medical record may be requested from The Everett Clinic.
•This form only authorizes access through MyChart and does not authorize release of medical records by other methods or in other formats.
•I understand that once information has been disclosed, it potentially may be re-disclosed and the disclosed information may not be covered by federal privacy protections.
•I am aware that The Everett Clinic does not condition any health care treatment, payment, or other services on signing this authorization.
CON-160 11/11 (CONSENT)