Name: | DOB: | MRN: | PCP:

Request MyChart Access to your Child's Record

Thank you for your interest in Seattle Children's MyChart, a free application where you can access your medical record. Learn More

This form is for a legal guardian of a Seattle Children’s patient to request access to the child’s information via MyChart (proxy access). In order to complete your request, it is required that we have legal documentation on file that the requesting person is a legal guardian. We are not able to grant access to anyone outside of legal guardians.

If you would like access to more than one patient, please complete this form for each patient.

Please expect the application process to take up to 7 days. We will contact you if we have questions. Please note to check your email account’s spam folder.

Legal Guardian Information

Items marked with an * are required for this section.

Patient Information

Items marked with an * are required if you fill out this section.

PLEASE READ AND CERTIFY

By clicking below, I acknowledge that I have read, understand and agree to Seattle Children's MyChart terms and conditions. By signing as proxy, I represent that I am the legal guardian of the patient and can consent to release of the information for the patient named in this form.

I Certify: