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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).",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/parentguardian-access-to-the-online-mychart-record-of-a-patient-12-to-17-years-old-authorization-form/567603/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/parentguardian-access-to-the-online-mychart-record-of-a-patient-12-to-17-years-old-authorization-form/567603.png","ImageObject",442,249,{"name":88,"@type":89},"PakDamar76","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-16","2026-10-13",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Do both the child (12–17) and the parent/legal guardian have to sign this form?","Question",{"text":108,"@type":109},"Yes. 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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) .  \nRequirements for accessing a child’s record:  \n􀂾 Parent or guardian requesting access must have legal guardianship rights  \n􀂾 Parent/Guardian Access Authorization form must be completed and signed  \n􀂾 Each parent or individual requesting access must have his/her own MyChart account.  \nI understand that:  \n􀂾 I must have a MyChart account  \n􀂾 I must log in to MyChart with my own User ID & Password  \n􀂾 I must click on ‘My Family’s Records’ to access my child's medical information  \n􀂾 I agree to abide by the terms and conditions of the MyChart site  \n􀂾 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.  \n􀂾 This site is not a substitute for appropriate and timely contact with my physician.  \nParent/Legal Guardian access to a child’s record is revoked when:  \n􀂾 Parent/legal guardian or patient submits a request to revoke online access  \n􀂾 Patient turns 18 years old  \n􀂾 Patient advises Ann & Robert H. Lurie Children’s Hospital of Chicago or his/her independent physician practice of emancipated status  \n􀂾 Parent/parent or parent/patient access disputes cannot be resolved  \nCommunications 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.  \nIf 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.  \nIf 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.  \nParent/Guardian Access to the Online MyChart Record of a Patient  \n12 to 17 Years Old-Authorization Form  \nPlease enter Patient’s information below:  \nPatient’s Name:   Date of Birth:   Address:   Gender:   Male   Female  \n________________________________________________  \n----------------------------------------------------------------------------------------------------------------------------- ------- ---------------------- -------  \nTo be notified when new messages about the patient’s care are sent to MyChart, please list an e-mail address:  \n_________________________________________________________________________________________ _______  \nPlease enter Parent/Legal Guardian information below:  \nParent Name:   Date of Birth:   Address:   Phone number on file:   Relationship to patient:   Parent   Legal Guardian   Other (please specify:  )  \nNote: Access to patient's online record is only available to parents or individuals with legal guardianship.  \nDo you (parent/legal guardian) have an active MyChart account?   Yes   No  \nI 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","cbCaijcxBnr0q9TN","https://ap.wps.com/l/cbCaijcxBnr0q9TN","pdf",161949,"English","# Requirements and Procedures\n## Requirements for Accessing a Child’s Record\n## I Understand That\n## When Access Is Revoked\n# Authorization Form\n## Patient Information\n## Parent/Legal Guardian Information\n## Consent, Disclosure Authorization, and Signatures\n## Submission Instructions","[{\"question\":\"Do both the child (12–17) and the parent/legal guardian have to sign this form?\",\"answer\":\"Yes. The document states that both the child aged 12–17 and the parent/legal guardian must sign the attached form.\"},{\"question\":\"What are the key requirements to access a child’s MyChart record?\",\"answer\":\"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.\"},{\"question\":\"When can parent/legal guardian online access be revoked?\",\"answer\":\"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.\"}]","Parent/Guardian Access to the Online MyChart Record of a Patient 12 to 17 Years Old - Authorization Form | PDF",1791867108]