Name: | DOB: | MRN: | PCP:

MyChart Activation Code Request: New Proxy Account

Thank you for your interest in MyChart, a secure online portal. Biological and adoptive parents may be granted access to their child’s medical record information through MyChart at Cincinnati Children’s. This is called proxy access.

To request proxy access, please complete the form below. We will contact you by phone or email 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.

A valid form of photo identification is required before your request will be reviewed and approved.

Look for the link in the form below.

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 activation code through secure email within 7 business days, using the email address you specify on this form.


Step 1 | TELL US ABOUT YOU:

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



Step 2 | IDENTITY VERIFICATION:

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.)

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

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.



Step 3 | CHILD/PATIENT INFORMATION:

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



ADDITIONAL CHILD/PATIENT INFORMATION:

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



Step 4 | 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 an account can be provided. 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)