MyChart - Request to Access a Patient's Record

Use this form to request MyChart access to a patient. Enter information about the patient to whom you are requesting access as well as information about yourself. All fields are required.

Your Information:

First Name:

Last Name:

Date of Birth:

Legal Sex:

Phone:

Street Address:

City:

State:

ZIP:

Email:

Patient Information:

The person you are requesting MyChart access to.

First Name:

Last Name:

Legal Sex:

Date of Birth:

Patient's Relationship to You:

If other, please specify:

I certify that I have the legal right to this patient's medical information.