Name: | DOB: | MRN: | PCP:
The system will be going down starting on 08/13/2022 3:00 AM, and will be back up on 08/13/2022 6:00 AM.

MyChart Proxy Access Authorization Form

This page allows you to request access to your child's personal health record(MyChart).

Please note, you must access your child's account using your own MyChart login and password. If you do not have a MyChart account, or are not a current MetroHealth patient, you will receive an account access code upon approval of your proxy request.

Adult to Child MyChart Proxy Access:

  • Adult-Child(Access to a minor child's MyChart record):
    • If your child is age 0-12: You will be granted full access to your child's MyChart information.
    • If your child is age 13-17: You may authorize your child to have separate MyChart account and you may be granted partial or full access to your child's MyChart information. Partial access, when applicable, is due to the requirements of privacy laws and regulations.
    • Once your child is 18 or older, you will no longer have access to your child's MyChart information without his/her consent.
  • If you are not the legal guardian of a child, consent from the child's legal guardian must be obtained in order to be granted proxy access.

If you have a MyChart account, Log into MyChart to request proxy access.

* Required Field

Request Proxy Access For:

Requesting proxy access for:
Requestor information:


***Please Read and Certify***

By submitting this form I certify that I am the birth/adoptive parent or legal guardian of the child listed above and that all information I have provided is true and accurate. I also agree to the Terms and Conditions for use of the MyChart website provided by MetroHealth. I hereby request access to my child's online medical record. I understand that MyChart access is a privilege. The MetroHealth System may terminate MyChart access at any time, if I do not comply with the MetroHealth MyChart terms and conditions. To review the terms and conditions of use of the MyChart website at MetroHealth click here.