Proxy Access to Teen Patient Account: Ages 12-17
To request access to the MyChart record of a minor patient whose medical care you help manage, please complete this form. A “Proxy” may be a patient’s parent, legal guardian or Power of Attorney. The Proxy will be able to access portions of the health record, including the following items, which may be expanded or changed from time to time by Lurie Children’s: Immunizations, Problem List, Medications, Allergies, History, and messages with the patient’s providers.
State and Federal laws require the consent of the patient before the release of certain types of medical information to a parent, guardian or proxy, beginning at age 12. This type of information may be very sensitive or private. Because of these legal requirements, both the minor patient and the Proxy must sign this Authorization form. This Proxy Access expires when the patient revokes (takes back permission).
If you would like to fill out this form by paper, please click on this link to download the form.
Proxy Access to Adult Patient Account: Ages 18+
By signing, Patient and Proxy both agree to the following:
Please click here to download the authorization form needed for your access. Please complete the form and submit to your pediatrician's office for MyChart access.