Name: | DOB: | MRN: | PCP:

Proxy Access Request

Thank you for your interest in UH MyChart™, an easy-to-use internet tool that provides you quick and secure online access to some of your child's health information. If you are the parent or legal guardian of a University Health (UH) patient who is under the age of 18, you can complete this form to request “proxy access” to your child’s health information in the MyChart™ Patient Portal. Proxy access enables you to view your child’s health information in the Portal and, in some instances, communicate through the Portal with your child’s health care team. Please understand, as protected by law, certain information related to the health of a teenager may not be visible on MyChart if the healthcare provider determines excluding the information is in the best interest of the patient.

By signing this Portal Proxy Request and Authorization Form, I acknowledge and agree that:

I am the parent or legal guardian.

There are no court orders or restraining orders in effect limiting my access to my child’s medical records and/or information.

I am giving my permission for University Health System to disclose my child’s protected health information (PHI) through the MyChart™ Patient Portal, which may include, but is not limited to: health summary, current problem list, current medications, lab results, appointment information.

I will establish my own MyChart™ account in order to access my child’s MyChart™ account.

Once my child turns 18, he/she has the authority under Texas Law to create their own access to MyChart™.

If you are a patient over the age of 18 requesting access to your own record, please complete the Self Acess Request: Self Access Request

Parent/Guardian/Legally Responsible Person Information
 

Date of birth of the parent or legal guardian.

Requesting access for:
Method to receive UH MyChart™ activation code*
Child's Information
 
Relationship to Child*
Are you the legal guardian for this patient?
Are you a CPS caseworker or foster parent of the child?
 
Additional Child's Information
 
Relationship to Child*
Are you the legal guardian for this patient?
Are you a CPS caseworker or foster parent of the child?
 
Additional Child's Information
 
Relationship to Child*
Are you the legal guardian for this patient?
Are you a CPS caseworker or foster parent of the child?
 
Certification

I certify that I am the patient or legally authorized representative of the patient. By signing this form, I acknowledge that I have read and understand this UH MyChart™ Request Form and I agree to its terms and conditions . I hereby request access to my child and/or children’s online health record.

Certification*

If you have any questions, please contact the Health Information Management office at 210-358-1777.