Mychart Child Proxy Form PDF Details

If you are a parent with a child under the age of 18, you will want to fill out a Mychart Child Proxy Form. This form gives permission for your child to have access to their medical information on The form is quick and easy to fill out, and can be completed online or printed out and mailed in. Having access to your child's medical information can be helpful if you need to make decisions about their care.

You will discover details about the type of form you would like to complete in the table. It will show you the amount of time you will need to finish mychart child proxy form, what parts you need to fill in, and so on.

Form NameMychart Child Proxy Form
Form Length2 pages
Fillable fields28
Avg. time to fill out6 min 6 sec
Other nameselmhurst mychart, MyChart, my chart edwards, Childs

Form Preview Example

MyChart Child Proxy Form

Access to Your Child’s MyChart Record

To sign up for access to your child’s MyChart record, please complete both pages of this Child Proxy Form. Please note that your child’s chart will be accessed through your MyChart record. Completing this form will establish a MyChart record for you (the parent) with access to your child’s medical information.

Return all forms to: Your Primary Care Provider Office.

Parent/Guardian Information: (All sections required – please print clearly.)

Name (last, first, middle initial) _______________________________________________________________

Social Security Number: _______________________________ Date of Birth: _______________________

Street Address: ________________________City: ________________________State: _____ Zip:_______

Email Address: ________________________ Phone Number: __________________

Primary Clinic: _________________________________________________________________________

Requirements for accessing a child’s record:

Birth/adoptive parent or individual requesting access must have legal guardianship rights

Complete and signed MyChart Child Proxy Form

Each parent or individual requesting access must have their own MyChart account

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.

If your child is age 0-14: You will be granted full access to your child’s MyChart record.

When your child turns age 15: Your access to your child’s MyChart record will expire.

Please provide the following information for each child: (All fields are required. If you have more than three children for whom you would like proxy access, please request another form or download one at

A. Name (last, first, middle initial): ____________________________________________________________________

Social Security Number: _________________________________ Date of Birth: _____________________________

Primary Clinic: __________________________________________________________________________________

B. Name (last, first, middle initial): ____________________________________________________________________

Social Security Number: _________________________________ Date of Birth: _____________________________

Primary Clinic: __________________________________________________________________________________

C. Name (last, first, middle initial): ____________________________________________________________________

Social Security Number: _________________________________ Date of Birth: _____________________________

Primary Clinic: __________________________________________________________________________________

Please remember to complete page 2 of this form.

MyChart Child Proxy Form (page 2)

MyChart Terms and Agreement

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 and can be obtained online at


Signature of Parent/Guardian

Relationship to Patient



How to Edit Mychart Child Proxy Form Online for Free

The PDF editor was designed with the goal of allowing it to be as effortless and easy-to-use as possible. All of these steps will make managing the DuPage simple.

Step 1: Choose the button "Get form here" to open it.

Step 2: Once you have entered the editing page DuPage, you should be able to find every one of the functions available for your document in the top menu.

Create the DuPage PDF and provide the information for every single part:

entering details in mychart elmhurst step 1

In the SocialSecurityNumberDateofBirth, PrimaryClinic, BNamelastfirstmiddleinitial, SocialSecurityNumberDateofBirth, PrimaryClinic, CNamelastfirstmiddleinitial, SocialSecurityNumberDateofBirth, and PrimaryClinic box, note down your details.

Filling in mychart elmhurst step 2

The program will request for extra info in order to easily fill out the segment MyChartChildProxyFormpage, SignatureofParentGuardian, RelationshiptoPatient, Date, and Time.

step 3 to entering details in mychart elmhurst

Step 3: Click the button "Done". Your PDF document can be transferred. It's possible to save it to your device or email it.

Step 4: Produce copies of the document. It will protect you from possible future complications. We cannot see or share the information you have, hence be sure it will be safe.

Watch Mychart Child Proxy Form Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .