Name: | DOB: | MRN: | PCP:

MyChart Activation Code Request: New Proxy Account

Thank you for your interest in MyChart, a secure online portal. Parents and primary caregivers can be granted proxy access to their child’s medical record information through MyChart at Cincinnati Children’s. 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.

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

Look for the link in the form below.

For patients age 13-17 who are not of diminished capacity, MyChart access must be requested and created in person.

Please ask one of our front-desk staff, or a member of the Cincinnati Children’s Family Resource Center, during your next visit.

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


Tell Us About You:

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


IDENTITY VERIFICATION REQUIRED:

To ensure that your and/or your child’s 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).



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)?



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