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The document lists eligibility requirements, required parent/guardian identifiers and account prerequisites, and conditions under which proxy access is revoked, including written revocation to the HIM Department and the child reaching age 13. 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To request parental access to the MyChart of a minor patient under 13 years old, please complete this form.  \nRequirements for parental proxy access to the MyChart of a minor patient under 13 years old:  \n􀁸 The individual requesting parental access must be the parent or legal guardian of the minor child under 13 years old.  \n􀁸 The parent/legal guardian’s completed and signed Request/Authorization for Parental Proxy Access to MyChart of Minor Patient Under 13 Years Old (this form) .  \n􀁸 The parent/legal guardian must have an email address.  \n􀁸 The parent/legal guardian must have a MyChart account.  \nBy requesting proxy access to your child's MyChart, you understand and agree to the following:  \n􀁸 The parent/legal guardian’s proxy access to their child’s MyChart is revoked when:  \no The parent/legal guardian submits a written request to revoke proxy access by sending the request to: Main Line Health HIM Department, 3803 West Chester Pike, Ste. 160, Newtown Square, PA 19073. Your revocation will not affect any disclosures that were made prior to processing the revocation;  \no Child turns 13 years old – at which time you may be eligible to receive limited adolescent (ages 14-17) proxy access, subject to your child’s authorization and in accordance with applicable law and Main Line Health policies;  \no Child advises Main Line Health of their emancipated status; or  \no Access disputes cannot be resolved.  \n􀁸 You must have a MyChart account or one will be established for you by Main Line Health.  \n􀁸 You must login to MyChart with your own user id and password.  \n􀁸 You must click “View Other Records” to access a patient’s online records.  \n􀁸 When you are signed in to your child’s record, your child’s name will be displayed in the header.  \n􀁸 Communications via MyChart on behalf of your child must be sent from your child’s record and responses will be received in your child’s record.  \n􀁸 You must abide by the MyChart Terms and Conditions of Use.  \n􀁸 You are not required to use MyChart or agree to MyChart parental proxy access.  \n􀁸 Main Line Health reserves the right to revoke on-line access to protected health information via MyChart at any time.  \nMake sure to complete Page 2 of this document  \nMLH901-958.1225 Page 1 of 2  \nLankenau Medical Center Bryn Mawr Hospital Paoli Hospital Riddle Hospital  \nPatient Information (Minor Child Under 13 Years Old)  \nFirst Name:   Last Name:    \nDate of Birth (mm/dd/yyyy):   Social Security Number (last 4 digits):    \nStreet Address:    \nCity:   State:   Zip:    \nPhone Number:    \nParent/Legal Guardian Information (Person requesting access to the patient’s MyChart)  \nFirst Name:   Last Name:   \nDate of Birth (mm/dd/yyyy):   Social Security Number (last 4 digits):    \nIf Proxy’s mailing address is the same as patient, check here: ________ (If different, complete below)  \nStreet Address:    \nCity:   State:   Zip:    \nEmail Address:   Phone Number:    \nProxy Relationship to Patient:   Parent   Court Appointed Legal Guardian  \nIf Other, please specify    \nDo you (Proxy) have an active My Main Line Health Chart account?   Yes   No   Don’t know  \nI have read, understand, and agree to the terms on Page 1 of this form and understand the requirements and procedures regarding parental proxy access to the MyChart of my child under 13 years old. I also hereby affirm that I am the parent or legal guardian identified above and all information I provided is correct. I understand that I may be subject to penalties under law for submitting false or misleading information related to this Request/Authorization for Parental Proxy Access. I hereby request access to the MyChart of the patient named above","cbCaiqcXRu43AMvI","https://ap.wps.com/l/cbCaiqcXRu43AMvI","pdf",189938,"English","# Request/Authorization for Parental Proxy Access to MyChart\n## Eligibility requirements\n## Terms for proxy access revocation and responsibilities\n## Patient and parent/legal guardian information\n## Submission methods","[{\"question\":\"Who is eligible to request parental proxy access to a minor’s MyChart?\",\"answer\":\"A parent or court-appointed legal guardian of a minor child under 13 years old is eligible to request access.\"},{\"question\":\"What requirements must the parent/legal guardian meet before requesting access?\",\"answer\":\"The requester must be the minor’s parent/legal guardian, provide a completed and signed authorization form, have an email address, and have a MyChart account (or have one established by Main Line Health).\"},{\"question\":\"When is parental proxy access to MyChart revoked?\",\"answer\":\"Proxy access is revoked if the parent/legal guardian submits a written revocation to the Main Line Health HIM Department, when the child turns 13, if the child advises Main Line Health of an emancipated status, or if access disputes cannot be resolved.\"}]","AuthorizationRequest for Parental Proxy Access for Minor Patient Under 13 Years Old | PDF",1791845195]