Manage Family Records

How to obtain MyChart proxy access

Download the Proxy Access Form

To manage your family's medical record, please download the form, complete it and follow the appropriate steps below for your situation:

MyChart Proxy request – ADULT to MINOR

1. Obtain Request for MyChart Proxy Access form from provider office/hospital or download the proxy access form here.
2. Complete Request for MyChart Proxy Access form
3. Submit completed Request for MyChart Proxy Access form and copies of required supporting legal documentation (see list below) to participating clinic or the Health Information Management (Medical Records) Department of the specific hospital where patient last received services

Legal Documentation

• If you are biological or adoptive parents please provide:
  Copy of Birth Certificate (reflecting parent’s name)
  or
  Patient Date of Birth and any two of the following relating to the patient:
  • Social Security Number
  • Account Number
  • Date of Service
  • Street Address
  • Insurance Carrier Name
  • Insurance Policy Numbe
  • Medical Record Number
  • Copy of Insurance Card
• If you are a Legal Representative (foster parents, case worker, etc.) please provide:
  Copy of court order for guardianship

MyChart Proxy request – ADULT to ADULT

1. Obtain Request for MyChart Proxy Access form from provider office/hospital or download the proxy access form here.
2. Complete Request for MyChart Proxy Access form
3. Submit completed Request for MyChart Proxy Access form and copies of required supporting legal documentation establishing guardianship authority (see list below) to participating clinic or the Health Information Management (Medical Records) Department of the specific hospital where patient last received services
   Legal Documentation.

• If you are a Legal Representative for the adult patient please provide one of the following:
  Copy of a court order establishing guardianship
  or
  Copy of medical power of attorney paperwork with proof patient is incapacitated.

Response time: You can expect a response to your request within 3 business days.

Questions: Call the MyChart Patient Support Line toll free at 1-855-274-2517 or Health Information Management centralized Release of Information at 303-467-4046.