Edwards Health My Chart 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 Mychart.com. 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.

QuestionAnswer
Form NameMychart Child Proxy Form
Form Length2 pages
Fillable?Yes
Fillable fields28
Avg. time to fill out6 min 6 sec
Other namesDMG, my chart edwards, edward elmhurst mychart, Pennsylvania

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 https://mychart.fmolhs.org/MyChart

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 https://mychart.fmolhs.org/MyChart

___________________/___________/___________/_______

Signature of Parent/Guardian

Relationship to Patient

Date

Time

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