MyChart Family Access

You may request access to another patient’s MyChart account to view their health information. Please select the appropriate authorization form below, print and return the completed form to this address.

MyChart Support
1236 Barberry Dr.
Janesville WI 53546

Fax: 608-314-8722
Contact MyChart Support at 888-99MYCHART (888-996-9242) with any questions.

Adult Requesting Access to Another Adult (18 years of age and older): To request access to view another adult patient’s MyChart account, the patient’s signed consent will also be required in order to be granted access. You will have access to everything the patient would have access to in their own account. Please keep in mind that the patient can revoke your access at any time, if they so choose. Please print and complete the following form.

Adult Proxy Request Form – English

Adult Proxy Request Form – Spanish

Parent Requesting Access to Minor Age 0-11: As the parent or legal guardian, you will be granted full access to your child’s MyChart account. To request access, print and complete the following form.

Child Proxy Request Form (0-11 years old) – Fill out electronically in English

Child Proxy Request Form (0-11 years old) – Print in English

Child Proxy Request Form (0-11 years old) - Print in Spanish

Parent Request Access to Minor Age 12-17: Under State and Federal law, there are certain types of medical information that the parent or legal guardian of a child age 12 to 18 may not view without the child’s consent. Because of these requirements, a parent or legal guardian will have limited access to their child’s account which includes allergies and immunizations on file. To gain full access, both the child and the parent or legal guardian must print and complete the following form. This access expires once the child turns 18 unless access is previously revoked by the child.

Child Proxy Request Form (12-17 years old) – Print in English

Child Proxy Request Form (12-17 years old) – Print in Spanish