Mychart Child Proxy Form PDF Details

Embarking on the journey of managing your child's health records can feel like navigating through a maze of medical documents and protocols. However, the MyChart Child Proxy Form simplifies this process by providing a streamlined path for parents and guardians to access their child's MyChart medical record. This critical tool is designed for those who wish to closely monitor and manage their child's health information through the MyChart platform. To commence the process, it is essential that the proxy form, encompassing two pages, be fully completed and submitted, typically to the primary care provider's office. The form necessitates detailed information about the parent or guardian, including their name, contact details, and social security number, asserting the importance of clarity and accuracy. It's worth noting that access to a child's MyChart record requires the parent or guardian to have legal guardianship rights and an individual MyChart account, ensuring a secure and personalized experience. Moreover, the form outlines age-specific access rights, granting full access to children aged 0-14, with an automatic expiration as the child turns 15, albeit this does not limit legal rights to access the records by other means. The form also includes a section for the acknowledgment of MyChart's terms and conditions, emphasizing the importance of understanding and agreeing to these provisions before gaining proxy access. This thoughtful approach not only prioritizes the child's health and privacy but also empowers parents and guardians with the necessary tools to be actively involved in their child's healthcare journey.

Form NameMychart Child Proxy Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other nameselmhurst hospital my chart, DMG, DuPage, mychart elmhurst edwards

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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 Pennsylvania simple.

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

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

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

entering details in DuPage step 1

In the Please provide the following, A Name last first middle initial, Social Security Number Date of, Primary Clinic, B Name last first middle initial, Social Security Number Date of, Primary Clinic, C Name last first middle initial, Social Security Number Date of, Primary Clinic, and Please remember to complete page box, note down your details.

Filling in DuPage step 2

The program will request for extra info in order to easily fill out the segment MyChart Child Proxy Form page, MyChart Terms and Agreement, By signing below I acknowledge, Signature of ParentGuardian, Relationship to Patient, Date, and Time.

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