Name: | DOB: | MRN: | PCP:

MyChart Account Update Request: Add Child(ren)

Thank you for your interest in MyChart at Cincinnati Children's. To add a child to your existing account, please complete the form below. We will contact you by phone if we have any questions regarding the information provided.

IMPORTANT REQUIREMENTS:

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

The patient must be between the ages of 0 and 17.

This form can also be used to request access to patients 18 and over with diminished capacity. Appropriate proof of ongoing legal guardianship is required.

Unfortunately, at this time, MyChart access cannot be granted to foster parents, social workers, or other family members.

Once your request has been approved, we will send you an email confirmation within 7 business days after your account is updated.


Step 1 | TELL US ABOUT YOU:

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




Step 2 | CHILD/PATIENT INFORMATION:

Please provide information for the child for whom you are requesting access. It is not necessary to provide the name(s) and information for children to whom you already have access.


Does your child have diminished capacity (e.g., cognitive or developmental delay)?



ADDITIONAL CHILD/PATIENT INFORMATION:

Please provide information for the child for whom you are requesting access. It is not necessary to provide the name(s) and information for children to whom you already have access.


Does your child have diminished capacity (e.g., cognitive or developmental delay)?



Step 3 | PLEASE READ AND SIGN THIS FORM:

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 your account can be updated. Violations of these terms may result in loss of access to MyChart. Once you have read this document, please sign this form below.


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