MyChart - Request to Access a Minor's Record

This form should be completed by a parent or permanent legal guardian (“Proxy”) who wants access to portions of his/her minor’s electronic protected health information (“ePHI”) through MyChart maintained by Aspen Valley Hospital and affiliated physicians.

Your Information:

First Name:

Last Name:

Date of Birth:

Legal Sex:

Phone:

Street Address:

City:

State:

ZIP:

Email:

Minor Information:

The person you are requesting MyChart access to.

First Name:

Last Name:

Legal Sex:

Date of Birth:

Medical Record Number (if known):

Phone:

Street Address (if different from requester):

City:

State:

ZIP:

Relationship:

If other, please specify:

I certify that I have the legal right to this minor's medical information.

By submitting this request, I acknowledge and agree that:

I will be using my own MyChart account to access the Child’s MyChart account.
I will comply with the MyChart Terms and Conditions for use of MyChart, available upon activation of a MyChart account.
I will keep my password confidential and not share this information with anyone.
I must have parental rights or permanent legal guardianship rights to access this Child’s record.
There are no court orders in effect limiting or denying my access to this Child’s medical records and/ or information.
There are age range limitations for MyChart. These age range limitations do not affect any legal right I have to access the Child’s record by other means. I can request a paper copy of the Child’s record by contacting the Health Information Management department.
For a child age 0 to 12 years, I will be granted full access to the Child’s MyChart account. On the Child’s 13th birthday, I will no longer have access to the Child’s MyChart account.
I may revoke this authorization at any time directly in MyChart.
I have a right to receive a copy of this authorization.
If my parental or legal guardianship rights change, I will notify Community Medical Centers.