MyChart -

Thank you for your interest in MyChart at Akron Children's Hospital. You are just a few steps away from secure, 24/7 access to your family’s health information.

To sign up for access, 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.

Parent/Legal Guardian Information

First Name:

Middle Name:

Last Name:

Date of Birth (xx/xx/xxxx):

Address:

City:

State:

Zip Code:

Phone (xxx-xxx-xxxx):

Email Address:

Drivers License or State ID Number:

Requesting Access for:

Existing Akron Children's MyChart AccountNew Akron Children's MyChart Account

Patient Information

Patient First Name:

Patient Middle Name:

Patient Last Name:

Date of Birth (xx/xx/xxxx):

Provider that certified patient as diminished capacity:

Your relationship to the patient:

MotherFatherLegal Guardian*Durable Power of Attorney for Healthcare (DPOA)*

*Legal Guardian must have a copy of court order supporting legal guardianship

*Durable Power of Attorney for Healthcare must have a copy of the DPOA

PLEASE READ AND CERTIFY

I am the parent, legal guardian or DPOA of the patient listed above. All information I have provided is correct. By signing this form, I acknowledge that I am authorized to access information on the above patient via MyChart 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 have the legal right to this patients medical information.

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Akron Children's Diminished Capacity MyChart Proxy Enrollment Form

Parent/Legal Guardian Information

Patient Information

PLEASE READ AND CERTIFY