1031-MyChart Proxy-Child

Patient Name: ____________________________________ 

Date of Birth: _____________________________________ 

MyChart Proxy Request Form 

CHILD 

Medical Record #: _________________________________ 

Place Patient Label 

To request access to your child’s MyChart record, please complete this form and either return it to the office of your child’s 

provider or to the Rush Health Information Management Office via email to mychartrequest@rush.edu, fax to (312) 942- 

5549, or mail to the following address: Rush Health Information Management Office, MyChart Proxy Request, 1611 W. 

Harrison St., L1 – Suite 001, Chicago, IL 60612. 

Rush will process this request within 5 business days of receiving this completed form. To access your child’s MyChart 

record, log in to your own MyChart account. If you do not have a MyChart account, you will receive a MyChart activation 

code so that you can sign up for MyChart and create your own MyChart account. To receive your activation code by email, 

check the box at the bottom of this form and provide a valid email address. Once you receive your activation code, sign up 

for MyChart at mychart.rush.edu. After completing the online sign up process, you can then log in to your MyChart account 

to access your child’s record. 

Please note the following age range limitations for MyChart: 

• You will receive full access to your child’s record only if your child is age 0 to 11 

• If your child is age 12 to 17, you will not be granted access to your child’s MyChart record. 

• Once your child reaches age 12, your proxy access to your child’s MyChart record will expire. 

These limitations do not affect any legal right you have to access your child’s medical record by other means. For information 

on how to obtain a print copy of your child’s record, call the Rush Health Information Management Office at (312) 942-7262. 

Parent or Guardian’s Information (All sections required – please print clearly.) 

Name (Last, First, Middle Initial): ___________________________________________ 

Date of Birth: ________________ 

Email Address: ________________________________________ 

Phone Number:________________________________ 

Street Address: _____________________________________________________________________________________ 

City:______________________________________________________ 

State: ________ Zip:______________________ 

Child’s Information (All sections required – please print clearly.) 

Complete this section with information about the child whose MyChart record you are requesting to access. 

Name (Last, First, Middle Initial): ___________________________________________ 

Date of Birth: ________________ 

Phone Number: ____________________________________________________________________________________ 

Street Address: _____________________________________________________________________________________ 

City:______________________________________________________ 

State: ________ Zip:______________________ 

MyChart Terms and Agreement 

I understand that MyChart is intended as a secure online source of confidential medical information. If I share my MyChart 

username and password with another person, that person may be able to view my or my child’s health information, and 

health information about someone who has authorized me as a MyChart proxy. I agree that it is my responsibility to select 

a confidential password, protect my password, and to change my password if I believe it may have been compromised in 

any way. 

RUSH1031 (11-27-13) PAGE 1 OF 2

Patient Name: ____________________________________ 

Date of Birth: _____________________________________ 

MyChart Proxy Request Form 

CHILD 

Medical Record #: _________________________________ 

Place Patient Label 

I understand and agree that MyChart may contain selected, limited information from my child’s medical record, including but 

not limited to test results and records related to genetic testing, genetic counseling, drugs and alcohol, HIV, mental 

health and developmental disability and agree to the release of such information to MyChart and that MyChart does 

not reflect the complete contents of the medical record. I also understand that a paper copy of my child’s medical record may 

be requested from Rush. 

I understand that my activities within MyChart may be tracked by a computer audit and that entries I make may become part 

of my child’s medical record. I understand that access to MyChart is provided by Rush as a convenience to its patients and 

that Rush has the right to deactivate access to MyChart at any time for any reason. I understand that use of MyChart is 

voluntary and I am not required to use MyChart or to authorize a MyChart proxy. 

The full MyChart Terms and Conditions and Proxy Terms and Conditions can be found at mychart.rush.edu. 

By signing below, I acknowledge that I have read and understand this MyChart Proxy Request Form and agree to its terms 

and further understand that the Proxy access terminates upon the child’s twelfth birthday. I further acknowledge that I will 

immediately notify Rush in the event I lose parental rights over the above named child and that my Proxy access shall 

immediately terminate upon the occurrence of such event. 

Signature of Parent/Guardian: _________________________________________ 

Date: __________________ 

Relationship to Child: ________________________________________________ 

If you would prefer your activation code delivered to a personal email account, provide the address below. 

Email address: ___________________________________________________________________ 

Initials: ___________ 

Witness Signature*: __________________________________________________ 

Date: ___________________ 

Witness Name (Please Print): ________________________________________________________________________ 

Relationship to Patient: _____________________________________________________________________________ 

* Signature of a witness is required because medical information released in MyChart may include test results and 

records related to genetic testing, genetic counseling, drugs and alcohol, HIV, mental health and developmental 

disability. 

RUSH1031 (11-27-13) PAGE 2 OF 2

1031-MyChart Proxy-Child

Create successful ePaper yourself

Delete template?

Save as template?