MyChart - Minor Proxy Access Request Form

Proxy access allows parents and legal guardians to request access to a minor's MyChart account by connecting their personal MyChart account to the minor they represent.

If you have questions about this form or are unable to locate the patient's Medical Record Number (MRN), please contact the University of Michigan School of Dentistry Central Records Department at (734) 764-6152, Monday through Friday, 8:00 a.m. to 3:00 p.m.

Requirements

You must be the parent or legal guardian of the patient to use this form. Supporting documentation may be required to verify your legal authority to request proxy access.

For Minor Patients

Please note that limitations to proxy access in MyChart may apply based on the patient's age. These limitations do not affect any legal right you have to access your child's health record.

Age 0-12: Full access to available MyChart features.
Age 13-17: Partial access to available MyChart features.
Age 18 or older: Parent or guardian proxy access expires. The adult patient must authorize continued access or appropriate legal documentation must be provided.

Parent or Legal Guardian Last Name:

Parent or Legal Guardian First Name:

Parent or Legal Guardian Date of Birth (mm/dd/yyyy):

Country:

Address:

City:

State:

Zip Code:

Phone Number:

Relationship to Patient:

If Other, Please Specify:

Email Address:

Re-enter Email Address:

Minor Patient Information

Patient Last Name:

Patient First Name:

Patient Date of Birth (mm/dd/yyyy):

Medical Record Number (xxxxxxxx):

I certify that I am the parent or legal guardian of the minor listed above and am authorized to request proxy access to the minor's MyChart account.