Proxy Access Request

Thank you for your interest in MyChart. Learn more about key features in our MyChart Overview.

To sign up for a Children's Health MyChart account, complete the appropriate form and submit it for approval. When your request is approved, we will email you a signup link.

  • If you are the parent or legal guardian of a Children's Health patient under the age of 18, complete the Proxy Access Request Form.
  • If you are a Children's Health patient over the age of 18 requesting access to your own record, complete the Self-Access Request Form.

Learn more about the types of accounts we provide. >

Proxy Access Request
Self-Access Request
Parent/Legal Guardian's Information
Indicates required fields

Date of birth of the parent or legal guardian.

Requesting access for:
Child's Information
Relationship to Child
Are you the guarantor for this patient?
Additional Child's Information
Relationship to Child
Are you the guarantor for this patient?
Additional Child's Information
Relationship to Child
Are you the guarantor for this patient?
Certification

I certify that I am the patient or legally authorized representative of the patient. By signing this form, I acknowledge that I have read and understand this Children’s Health MyChart Request Form and I agree to its terms and conditions. I hereby request access to my child's and/or children’s online health record.

If you have any questions, please contact the Health Information Management office at 214-456-2503.
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