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MyChart Proxy Access Consent Forms

To request access to another patient's record, you must first fill out the appropriate consent form. These forms are also available at your physician's office. For your convenience, you may print out the applicable form and fill it out in advance. Forms must be returned in person to your physician's office or to the Medical Records Department where your visit occurred. You will be asked to provide a photo ID as proof of your identity.

Please be sure to fill out the correct form depending on your relationship to the patient you are requesting access to and the age of the patient. Before completing a form, please review the general proxy access terms and conditions of use.

I would like to request access to my child's record
My child is under twelve years of age
My child is between twelve and seventeen years of age
I would like to request access to another adult's record
Another adult is granting me permission to access their record
I am the legal guardian or healthcare Power of Attorney for another adult

My child is under twelve years of age

Download the Child Proxy Access Consent Form

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My child is between twelve and seventeen years of age

Download the Teen Proxy Access Consent Form
Please note, your teen child must provide their consent.

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Another adult is granting me permission to access their record

Download the Adult Proxy Access Consent Form
Please note, the adult granting you access to his/her account will need to provide their consent.

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I am the legal guardian or healthcare Power of Attorney for another adult

Download the Diminished Capacity Adult Proxy Access Form
Please note, you will need to bring a copy of any legal documents related to guardianship or power of attorney to your doctor's office or the Medical Records Department when submitting this form.


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