Parent/Guardian Access to the Online MyChart Record of a Patient 12 to 17 Years Old - Authorization Form

Oct 13, 2026

Authorization form for parents or legal guardians to access a minor patient’s online MyChart record for ages 12–17. Explains that access requires the minor patient’s consent and both parties sign the attached form. Lists requirements such as legal guardianship, completion of the authorization, and separate MyChart accounts. Details how account access is granted, how activation works if no MyChart exists, and when access is revoked (including when the patient turns 18 or status disputes).

LanguageEnglish

CategoryForms

FormatPDF

Pages3

Reading Time1 min

AccessFree to download

Requirements and Procedures

Requirements for Accessing a Child’s Record

I Understand That

When Access Is Revoked

Authorization Form

Patient Information

Parent/Legal Guardian Information

Consent, Disclosure Authorization, and Signatures

Submission Instructions

Parent/Guardian Access to the Online MyChart Record of a Patient 12 to 17 Years Old Requirements and Procedures Under State and Federal law there are certain types of medical information that the parent or guardian of a minor patient age 12-17 may not view without consent of the minor patient. Because of these requirements, a parent or legal guardian may access the online MyChart record of a patient 12-17 years old only with the patient’s consent. Both the child aged 12-17 and the parent/legal guardian must sign the attached form (below) . Requirements for accessing a child’s record: 􀂾 Parent or guardian requesting access must have legal guardianship rights 􀂾 Parent/Guardian Access Authorization form must be completed and signed 􀂾 Each parent or individual requesting access must have his/her own MyChart account. I understand that: 􀂾 I must have a MyChart account 􀂾 I must log in to MyChart with my own User ID & Password 􀂾 I must click on ‘My Family’s Records’ to access my child's medical information 􀂾 I agree to abide by the terms and conditions of the MyChart site 􀂾 MyChart is not to be used in emergency situations. If I have a medical emergency or have a question about medical care or treatment, I will contact my health care provider directly. 􀂾 This site is not a substitute for appropriate and timely contact with my physician. Parent/Legal Guardian access to a child’s record is revoked when: 􀂾 Parent/legal guardian or patient submits a request to revoke online access 􀂾 Patient turns 18 years old 􀂾 Patient advises Ann & Robert H. Lurie Children’s Hospital of Chicago or his/her independent physician practice of emancipated status 􀂾 Parent/parent or parent/patient access disputes cannot be resolved Communications on behalf of the patient must be sent from the patient’s record; responses will be posted in the patient’s record. MyChart e-mail alerts will be sent to the e-mail address entered in the patient’s record. If you already have a MyChart account, you will receive a letter notifying you that access to the patient’s record is available, typically 5-7 business days. You will be granted access to the record only after the completed Parent/Guardian Authorization form is received. If you do not have a MyChart account, upon submitting your electronic request a MyChart Activation Letter with Access Code and instructions will be mailed to you typically in 5-7 business days. Access to MyChart will be accessible upon Lurie Children’s or your independent physician practice receiving the completed Parent/Guardian Authorization form. If you do not activate your account within 60 days after receiving your MyChart Activation Letter, your account will be inactivated. Parent/Guardian Access to the Online MyChart Record of a Patient 12 to 17 Years Old-Authorization Form Please enter Patient’s information below: Patient’s Name: Date of Birth: Address: Gender: Male Female ________________________________________________ ----------------------------------------------------------------------------------------------------------------------------- ------- ---------------------- ------- To be notified when new messages about the patient’s care are sent to MyChart, please list an e-mail address: _________________________________________________________________________________________ _______ Please enter Parent/Legal Guardian information below: Parent Name: Date of Birth: Address: Phone number on file: Relationship to patient: Parent Legal Guardian Other (please specify: ) Note: Access to patient's online record is only available to parents or individuals with legal guardianship. Do you (parent/legal guardian) have an active MyChart account? Yes No I have read and understand the requirements and procedures for accessing my child’s medical record information online as provided on page one of this document titled, Parent/Guardian Access to the Online My

FAQs

Do both the child (12–17) and the parent/legal guardian have to sign this form?

Yes. The document states that both the child aged 12–17 and the parent/legal guardian must sign the attached form.

What are the key requirements to access a child’s MyChart record?

The parent/guardian must have legal guardianship rights, complete and sign the Parent/Guardian Access Authorization form, and each requesting person must have their own MyChart account.

When can parent/legal guardian online access be revoked?

Access can be revoked if the parent/legal guardian or the patient submits a request to revoke online access, when the patient turns 18, if the patient reports emancipated status, or if access disputes cannot be resolved.

Oct 13, 2026

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