Mychart proxy 2026

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4.8 out of 5

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The document is a Child Proxy Form for accessing a child's MyChart interactive health record. It outlines the process for parents or guardians to sign up for access, including required information and age-related access limitations. The form emphasizes the importance of maintaining confidentiality and security of the MyChart account, as well as the responsibilities of the user regarding password management and email updates.

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Click ‘Get Form’ to open the mychart proxy form in the editor.
Begin by filling out the Parent/Guardian Information section. Ensure you provide your name, last four digits of your SSN, date of birth, address, email, and phone number clearly.
Select the primary care organization from the provided list that serves your child. This is crucial for establishing access.
Next, complete the Child’s Information section. Fill in your child's name, last four digits of their SSN, and date of birth accurately.
Again, select the primary care organization for your child from the same list.
Review the MyChart terms and agreement carefully. Ensure you understand each point before signing.
Finally, sign and date the form at the bottom to confirm your understanding and agreement.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (50 Votes)

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