MyChart -

To grant an adult access to your information in MyChart, please complete and submit the following form for approval. Once your request has been received, we will send a secure, activation email within 7 business days. We will contact you by phone or email if we have any questions.

Note: * indictates required field on the form.

MyChart Caregiver's Information

Caregiver's First Name:

Caregiver's Middle Name:

Caregiver's Last Name:

Caregiver's Date of Birth (xx/xx/xxxx):

Caregiver's Address:

Caregiver's City:

Caregiver's State:

Caregiver's Zip Code:

Caregiver's Phone (xxx-xxx-xxxx):

Caregiver's Email Address:

Caregiver's Drivers License or State ID Number:

Patient Information

Patient First Name:

Patient Middle Name:

Patient Last Name:

Patient Date of Birth (xx/xx/xxxx):

Patient Address:

Patient City:

Patient State:

Patient Zip Code:

Patient Phone (xxx-xxx-xxxx):

Patient Email Address:

Patient Drivers License or State ID Number:

As an adult patient of Akron Children's Hospital:

I am granting the named MyChart caregiver access to MyChart*

*For the purposes of this form, "you," "your," "my," and "I" mean the patient listed above whose record is maintained by Akron Children's Hospital. I hereby authorize the individual designated above ("MyChart caregiver") to act on my behalf regarding any and all of my health information contained in Akron Children's Hospital MyChart, which shall include, but not be limited to, receiving access to Akron Children's Hospital MyChart functions which allow my MyChart Caregiver to view, download, and/or transmit to third parties any and all of my health information, according to the Akron Children's Hospital MyChart Caregiver Terms and Conditions. As such, I hereby authorize Akron Children's Hospital to release via Akron Children's Hospital MyChart Caregiver Access any and all of my health information contained in Akron Children's Hospital MyChart to my MyChart Caregiver for any purpose that my MyChart Caregiver deems to be appropriate. I understand and acknowledge that this may include information relating to treatment for physical and mental illness, alcohol/drug abuse, and/or HIV/AIDS test results or diagnoses.

Once your health care information is released, your information may be re-disclosed by the recipient and may no longer be protected by law. Treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether you agree to this authorization. In order for this authorization to be valid, activation of the Akron Children's Hospital MyChart Caregiver access feature must occur within one (1) year of the date of this authorization. Upon receipt of this completed form, please allow approximately seven (7) business days for processing your request to designate a MyChart Caregiver.

This authorization for MyChart Caregiver's access to my Akron Children's Hospital MyChart account will automatically expire when Akron Children's Hospital receives notice of my death, when I (or my legal representative) deactivate(s) my Akron Children's Hospital MyChart account, or when I (or my legal representative) revoke(s) this authorization, whichever occurs first. You may revoke this authorization at any time, except to the extent that action has been taken in reliance upon it, through written notice sent to Akron Children's Hospital MyChart, 1 Perkins Square, Akron, Ohio, 44308 or by submitting a revocation request through your Akron Children's Hospital MyChart account.

PLEASE READ AND CERTIFY

I am an adult patient who is 18 years or older of Akron Children's Hospital. All information I have provided is correct. By signing this form, I acknowledge that I am authorizing MyChart proxy access to the named MyChart caregiver according to Akron Children's Hospital terms and conditions.

Click the statement to the right to sign this form electronically (It will turn blue when clicked):

Yes, I certify that I am granting MyChart caregiver access.

Back to the Login page

Akron Children's Adult Patient MyChart Proxy Enrollment Form

MyChart Caregiver's Information

Patient Information

PLEASE READ AND CERTIFY