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.


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

Adult-to-adult proxy access expires every 18 months. Therefore, if you want the proxy to have access to your medical record information through MyChart after 18 months, you will need to complete a new form.

If you have a personal MyChart account, you can use the MyChart Proxy Invite feature to renew access to a previously existing proxy.


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


To ensure that your/your child's information is protected and secure, a driver's license, passport, or state-issued identity card is needed to verify your identity. (Theme-park passes and basic photos will not be accepted.) Your photo identification (ID) will be used solely to verify identity and will not be permanently stored.

Click here to securely upload your photo ID. (A new window will open.)

Confirm upload of photo ID:

IMPORTANT: Your MyChart request will not be reviewed or approved until a valid form of photo identification has been received.

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.


*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.


You must read, understand, and agree to the terms described in our Cincinnati Children's 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.

Click the statement to the right to sign this form electronically (It will turn blue when clicked)

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.