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

Once your request has been approved, we will send you an email confirmation within 7 business days, using the email address you specify on this form.

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.


Tell Us About You:

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




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 your account can be updated. 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