MyChart -

Thank you for your interest in MyChart, a secure online portal. To request access to your medical record information, please complete the form below. We will contact you by phone or email if we have any questions regarding the information provided.

IMPORTANT REQUIREMENTS:

You must be an established patient at Cincinnati Children's in order to request a MyChart account online.

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

Once your request has been approved, we will send you an activation code through secure email within 7 business days.

Tell Us About You:

Today's Date:

First Name:

Middle Name:

Last Name:

Your Date of Birth:

Street Address:

City:

State:

Zip Code:

Mobile Phone (xxx-xxx-xxxx):

Email Address*:

*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?

Yes

Name on ID (if different than 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).

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

YES, I am the patient listed above. I sign this form electronically and certify that all information I have provided is correct. By signing this form, I acknowledge that I have read and understand the Cincinnati Children’s MyChart Agreement Form, and I agree to abide by the Terms and Conditions of Use posted on the MyChart website. I understand that a violation of such terms may result in loss of access to MyChart.

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MyChart Activation Code Request: New Patient Account

Tell Us About You:

PLEASE READ AND SIGN THIS FORM: