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MyChart Activation Request: Grant Adult Proxy Access

Thank you for your interest in MyChart, a secure online portal. If you are a patient Cincinnati Children's, and you are 18 years old or older, you may complete the form below to grant MyChart access to another adult. This type of MyChart access is called a proxy. Adult-to-adult proxy access expires every 18 months. Therefore, if you want another adult to have continued access to your medical record information through MyChart after 18 months, you will need to complete a new form.

IMPORTANT REQUIREMENT: A valid form of photo identification is required before your request will be reviewed and approved. Look for the link in the form below.


Tell Us About You:

*A valid email address is required to request a MyChart account.


IDENTITY VERIFICATION: To ensure that your information is protected and secure, a copy of your driver's license, state or school photo ID will be needed to verify your identity. Proof of identification can be provided using our secure document upload. (A new window will open.) You can also send this information to the Health Information Management (HIM) Department at Cincinnati Children's using secure fax, 513-487-4845. The ID will be used solely to verify identity and will not be permanently stored.


Were you able to successfully upload proof of identification as described above?

IMPORTANT: Your MyChart request will not be reviewed or approved until a valid form of photo identification has been received (e.g., driver's license or state photo ID).



I DO want the portions of my medical record (maintained by Cincinnati Children's Hospital Medical Center) that are available in the MyChart Patient Portal to be viewable by the person listed below. I understand that MyChart Patient Portal may include private information including my sexual history (for example, birth control medications). To make changes or to cancel this permission, I must call 1-877-508-7607 or 513-636-5019, Monday through Friday 8am-5pm.

I want to authorize Cincinnati Children's to grant access to the person below to MyChart Patient Portal to see my health information. I understand that I cannot limit the items available through MyChart Patient Portal to this person.



Grant Online Portal Access To:

*A valid email address is required to request a MyChart account.



This Authorization will expire 18 months after the date of this request. This Authorization may be revoked at any time to the extent that use and/or disclosure has not already occurred prior to my request for revocation. In order to revoke the Authorization, the patient must submit a revocation request in writing to the Health Information Management Department, 3333 Burnet Avenue, MLC 5015, Cincinnati, OH 45229. Please refer to Cincinnati Children’s Hospital Medical Center’s (CCHMC) Notice of Privacy Practices.

CCHMC will not condition treatment, payment, enrollment, or eligibility for benefits on the execution of this Authorization.

This information used or disclosed as a result of this Authorization may be subject to redisclosure by the person or entity receiving such information, and thus no longer protected by the federal privacy regulations.



PLEASE READ AND SIGN THIS FORM:

You must read, understand, and agree to the terms described in our Cincinnati Children’s MyChart Agreement Form and the Terms and Conditions of Use posted on the MyChart website before an account can be provided. Violations of these terms may result in loss of access to MyChart. Once you have read each of these documents, please sign this form below.


Sign this form electronically by clicking the box to the right

If CCHMC requests this Authorization for its own use or disclosure, a copy of this Authorization must be provided to the individual completing this form.