Parental Authorization Form - Parental Access to the Online Medical Record of a Child Under 13 Years Old

Sep 17, 2026

Parental Authorization Form for granting a parent or guardian access to a child’s MyChart online medical record for children under 13 years old. The form instructs parents/guardians to complete both pages and include a government-issued ID, then provide contact and parent/guardian details. It requires listing each child’s information and selecting the custody/authority basis, along with a signature and date. MyChart terms explain secure portal use, emergency guidance, tracking/audit, and automatic termination of proxy access when the child turns 13.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Parental Authorization Form

Parental Access to the Online Medical Record (Under 13)

Parent/Guardian Information

Child Information (A-D)

Authority to Obtain a Child’s Health Information

MyChart Terms and Agreement

Signature and Date

Office Use Only

Parental Authorization Form Parental Access to the Online Medical Record of a Child Under 13 Years Old To sign up for access to your child’s MyChart record, please complete both pages of this Parental Authorization Form and return to your physician’s office. 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 a government issued ID. You can return this form and a copy of your photo ID by: 1) Email [to clinic_message@snoqualmiehospital.org](to clinic_message@snoqualmiehospital.org) [2](2)) Fax to (425) 831-2361 3) In person at your provider’s office or hospital | PARENT/GUARDIAN INFORMATION: | | --- | | Name (last, first, middle initial): Date of Birth: | | Street Address: City: State: Zip: Email Address: Home Phone Number: | | Have you received any services at Snoqualmie Valley Health? ☐ YES ☐ NO | Please note that this form should not be used in the case of an emancipated minor. An emancipated minor should use the Adult Proxy Form. If your child is age 0-13, with the completion of a proxy authorization, you will be granted full access to your child’s MyChart record. When a child turns 13 years old, proxy access is automatically termed. Please provide the following information for each child. All fields are required. If you have more than four children, please request another form. 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: D. Name (last, first, middle initial): Date of Birth: Patient Address, if different from above: Authority to Obtain a Child’s Health Information: Check all that applies for each child: I am the child’s birth parent with current custody: ☐ Child A ☐ Child B ☐ Child C ☐ Child DI have been awarded custody of the child with the right to make health care decisions (attach court order(s) showing custody/rights): ☐ Child A ☐ Child B ☐ Child C ☐ Child D MyChart Terms and Agreement • I understand that MyChart is intended as a secure online portal for viewing confidential medical information. • I understand that for all medical emergencies, I need to immediately dial 911. • I understand and agree that access to protected health information within MyChart is subject to the MyChart Terms and Conditions. I understand that failure to comply with the terms and conditions of use for MyChart may result in the termination of MyChart access privileges. * • I understand that the medical information included in MyChart may include medical information considered very personal, including information about sexually transmitted and other communicable diseases, drug and alcohol abuse, HIV/AIDS, and mental health services. • I understand that when a child turns 13, parental proxy access is automatically terminated. I understand that patients age 13 and above must consent for the release of information for treatment of mental health and/or substance abuse and patients age 14 and above must consent for the release of information of treatment for birth control and/or sexually transmitted diseases. • I understand that my activities within MyChart may be tracked by computer audit and entries I make may become part of the medical record. • I understand that access to MyChart is provided by Snoqualmie Valley Health as a convenience to its patients and that Snoqualmie Valley Health has the right to deactivate access to MyChart at any time for any reason. | I have read, understand and agree to the terms and conditions set forth on this page, as well as the terms and conditions included on the webpage used to access MyChart. | | --- | | Signature of Parent/Guardian: Date: | | Relationship to Patient

FAQs

Who should complete this form and what is it for?

A parent or guardian should complete it to request access to a child’s MyChart online medical record for a child under 13 years old. Both pages must be completed and returned to the physician’s office.

What documents are required when submitting the form?

A government-issued ID must be included. The completed form and a copy of the photo ID can be returned by email, fax, or in person.

When does parental proxy access end?

When the child turns 13, parental proxy access is automatically terminated. Patients 13 and above must consent for release of certain mental health/substance abuse information, and patients 14 and above must consent for birth control and/or sexually transmitted disease treatment information.

Sep 17, 2026

Upload by Quinn Holloway