Name: | DOB: | MRN: | PCP:

Give Someone Else Access to your Record through MyChart

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 patients that are 18+ years old and would like to add a proxy to their account. You will need your own MyChart account to finalize this request.

Once we receive the below request, we will send you a message in MyChart to review and approve access, before the invitation is sent to the proxy you specified. Please note that you will be able to revoke the proxy yourself within MyChart.

Please expect the application process to take up to 7 days.

Your Information

Items marked with an * are required for this section.

Proxy Information

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

*Relationship to you:

PLEASE READ AND CERTIFY

Information I have provided above is correct and complete. I acknowledge that I have read and understand this Seattle Children's MyChart Consent Form and I agree to its terms and conditions.

I Certify: