HUMC MyChart Child Proxy Form - Sign up and request proxy access

Oct 13, 2026

Upload by Adam

Access the child’s MyChart record by completing both pages of the Child Proxy Form and returning it to the listed Hackensack Meridian Health address or fax. Provide two forms of identification, including a government-issued ID and proof of current address. This form creates MyChart access for both you and your child, with full access for ages 0–11, partial access for ages 12–17, and no access after age 18.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Access to Your Child’s MyChart Record

Required Documentation and Return Methods

Age Range Access Limits

Parent/Guardian Information

Child Information Entries

Eligibility Note for Emancipated Minors

Authority to Obtain Child’s Health Information

MyChart Terms and Agreement

Access to Your Child’s MyChart Record To sign up for access to your child’s MyChart record, please complete both pages of this Child Proxy Form and return it to the address shown below. Please note that your child’s chart will be accessed through your MyChart record. Completing this form will establish a MyChart record for you and for your child. You must include two forms of identification ,* one of which must be a government issued ID and an additional one that is proof of your current address. Return all forms to any of the following Health Information Departments: Hackensack University Medical Center, Health Information Department, 30 Prospect Avenue, Hackensack, NJ 07601 OR Fax: 201-489-0591; Jersey Shore University Medical Center, Health Information Department,1945 Route 33, Neptune, NJ 07753 OR Fax: 732 776-4692; Bayshore Medical Center, Health Information Department, 727 North Beers Street, Holmdel, NJ 07733 OR Fax: 732 888-7332; Ocean Medical Center, Health Information Department, 425 Jack Martin Blvd, Brick, NJ 08724 OR Fax: 732 840-9616; Riverview Medical Center, Health Information Department, 1 Riverview Plaza, NJ 07701 OR Fax: 732 224-7210; Southern Ocean Medical Center, Health Information Department, 1140 Route 72, Manahawkin, NJ 08050 OR Fax: 609 978-8965; Raritan Bay Medical Center, Health Information Department, 530 New Brunswick Avenue, Perth Amboy, NJ 08861 OR Fax:732 324-4883; Raritan Bay Medical Center, Health Information Department, One Hospital Plaza, Old Bridge, NJ 08857 OR Fax 732 360-4134. Palisades Medical Center, Health Information Management, 7600 River Road North Bergen, NJ 07047 OR Fax: 201-854-8360 John F Kennedy Medical Center, Health Information Management, 80 James St. Edison, NJ 08820 OR Fax 732-744-5639 Please note that this form should not be used in the case of an emancipated minor.1 An emancipated minor should use the Adult Proxy Form. To request a paper copy of your child’s record, contact the Health Information Department at Hackensack Meridian Health. Below are the following age range limitations for MyChart. 􀁸 If your child is age 0-11, you will be granted full access to your child’s MyChart record. 􀁸 If your child is age 12-17 , you will be granted partial access to your child’s MyChart record (e.g. , immunizations and allergies) . 􀁸 Once your child reaches age 18, you will no longer have access to your child’s MyChart record. Parent/Guardian Information: (All sections required – please print clearly. ) Name (last, first, middle initial): Date of Birth: Street Address: City: State: Zip: Email Address: Home Phone Number: Have you received services at a Hackensack Meridian Health facility? YES NO Please provide the following information for each child: All fields are required. If you have more than four children for whom you would like Proxy access, please request another [form or print one from](form or print one from www.HMHMyChart.org)[ ](form or print one from www.HMHMyChart.org)[www.HMHMyChart.org](form or print one from www.HMHMyChart.org). A. Name: (last, first, middle initial) Date of Birth: Patient address if different from above: B. Name: (last, first, middle initial) Date of Birth: Patient address if different from above: C. Name: (last, first, middle initial) Date of Birth: Patient address if different from above: Please remember to read and complete page 2 of this form. 1 In New Jersey, an “emancipated” minor is a person under the age of 18 who is: (a) is married,(b) pregnant, (c) in U.S. military service, or (d) declared emancipated by a court or administrative agency. Authority to obtain a child’s health information (check one): Check all that applies for each child. 􀁸 I am the child’s birth parent with current custody. 􀂅 Child A 􀂅 Child B 􀂅 Child C 􀂅 Child D Check all that applies for each child. 􀁸 I have been awarded custody of the child with the right to make health care decision

FAQs

What is the purpose of the MyChart Child Proxy Form?

It establishes a MyChart record for you and your child and enables proxy access to your child’s MyChart record.

What identification documents are required?

Include two forms of identification: one government-issued ID and an additional document proving your current address.

How does MyChart access vary by a child’s age?

Ages 0–11 receive full access, ages 12–17 receive partial access (such as immunizations and allergies), and access ends when the child reaches age 18.

Oct 13, 2026

Upload by Adam