Name: | DOB: | MRN: | PCP:

Child Proxy Access Request

The University of Chicago Medical Center (UCMC) is pleased to offer parents/legal guardians access to portions of their minor child's medical record online. You must have parental rights or legal guardianship to receive access to your minor child's MyChart account. By reading, completing and submitting this authorization, you are certifying that you have appropriate legal rights to access medical and health insurance information for the child indicated below. Your child's information will be accessed through your own MyChart account. If you do not have your own MyChart account, we will create an activation code for you.

PLEASE NOTE: In accordance with UCMC policy, proxy access converts to a limited version on the child's 12th birthday and proxy access terminates on the child's 18th birthday.

Birth to 12 Years of Age: Parents and legal guardians are provided with full access to their child's MyChart account. A week before your child's 12th birthday, you will receive an email alerting you that your access will be transitioned to a limited proxy access the day before your child's birthday.

12 to 17 Years of Age: Parents and legal guardians are provided with limited access to their child's MyChart account. A week before the child's 18th birthday, you will receive an email alerting you that access will be terminated the day before your child's birthday.

Children under the age of 18 are not permitted to have access to their own individual MyChart account.

After submitting this form, the Health Information Management office will review your information and send an email with an activation code to the address provided (within 5 business days). We will contact you via the phone number provided if there are any questions regarding the information you have submitted.

Only a child that has been seen by a provider at The University of Chicago Medicine will have a MyChart account.

*Required Field

CHILD'S INFORMATION:

Enter the text as you see it below.This proves you're a real person and not an automated program attempting to log in to your account.

***Please Read and Certify***

By submitting this form I certify that I am the birth/adoptive parent or legal guardian of the child listed above and that all information I have provided is true and accurate. I also agree to the Terms and Conditions for use of the MyChart website provided by The University of Chicago Medical Center. I hereby request access to my child's online medical record. I understand that MyChart access is a privelege. The University of Chicago Medical Center may terminate MyChart access at any time, if I do not comply with the UCMC MyChart terms and conditions. To review the terms and conditions of use of the MyChart website at UCMC click here.