MyChart: Authorization for Proxy Access to Patient Account

Which of the following describes your MyChart Proxy Access Request?*

Location for MyChart Access

Please note that if you would like access at multiple facilities, you will need to provide a separate form for each location.

Proxy Access to Teen Patient Account Age 12-17 Years Old


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 Age 18+ Years Old


Proxy Access to Adult Patient Account: Ages 18+

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.

Patient Information

Patient Name*
Patient Date of Birth*
Please keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed.
Address*

Proxy Information

Relationship to Patient*
No File Chosen
File uploads may not work on some mobile devices.
Please upload a scanned copy of the legal paperwork
Proxy Name*
Proxy Date of Birth*
Please keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed.
Do you have the same address as the patient?*
Address*

Signatures

By signing, Patient and Proxy both agree to the following:

  • MyChart should not be used in an emergency. Lurie Children’s will make its best effort to provide a timely response to electronic inquiries in MyChart, in accordance with the MyChart Terms and Conditions available in the MyChart portal. For emergencies, call 911.
  • MyChart is intended as a secure online portal for health information. MyChart contains a portion of patient’s health record and does not contain all the information that may be available with a complete copy, available from the Health Information Department. 
  • This form does not authorize release of patient’s medical records to Proxy by any other methods or form.
  • I understand that once I share my health information with others, it can be re-disclosed by them and the information may not be covered by federal privacy protections.
  • Passwords must be kept confidential. Tell Lurie Children’s MyChart HelpDesk at 833.706.4507 if a password has been lost or compromised.
  • Sensitive Health Information: with a MyChart Enhanced Proxy Access Account Proxy will have access to health information that is currently available and that may become available as a result of future medical care. Some of this health information may be sensitive or private. Proxy may have access to the  following types of information: information related to HIV/AIDS, behavioral or mental health, developmental disabilities, treatment for substance use disorder, genetic testing and counseling, artificial insemination, sexual assault/abuse, domestic abuse of an adult with a disability, child abuse and neglect, sexually transmitted illnesses, pregnancy, and birth control. Lurie Children’s can only provide a MyChart Enhanced Proxy Access Account with patient authorization. If patient does not provide this authorization, Proxy may receive a MyChart Standard Proxy Access Account with more limited access that avoids violation of privacy laws.
  • Activities and messages in MyChart may be tracked by computer audit and may become part of the health record.
  • MyChart e-mail alerts will be sent to the e-mail address entered in the patient’s record and on this form.
  • Access to MyChart is provided by Lurie Children’s as a convenience to its patients. Lurie Children’s has the right to deactivate access to MyChart at any time and for any reason.
  • Use of MyChart is voluntary. Lurie Children’s does not condition any of health care treatment, payment or other services on use of MyChart.
  • This authorization will expire when revoked (taken back). I may revoke this authorization at any time by contacting the MyChart HelpDesk at 833.706.4507. My revocation will not affect disclosures made prior to making the request.

Description Area

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Use your mouse or finger to draw your signature above

Community Connect MyChart Authorization Form

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.

PediaTrust MyChart Authorization Form

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.

PediaTrust MyChart Authorization Form

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.

Community Connect MyChart Authorization Form

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.

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