Name: | DOB: | MRN: | PCP:

Child Proxy Request Form

To request access to the Mercyhealth MyChart account of a child, please complete this form. Please note the following age range limitations.

If your child is age 0-11, you will be granted full access to your child’s Mercyhealth MyChart account.

Due to federal and state laws, if your child is age 12-17, you will be given limited access which includes allergies and immunizations. To obtain full access, you and your child must complete the Mercyhealth MyChart Child Proxy Request Form (12-17 years old).

Once your child reaches age 18, you will no longer have access to their Mercyhealth MyChart account.

* I understand that Mercyhealth MyChart is intended as a secure online source of medical information and contains a limited amount of medical information from a patient’s electronic medical record from all Mercyhealth facilities. It does not reflect the complete contents of the medical record. Access may include information related to behavioral or mental health, developmental disabilities, HIV/AIDS, treatment for substance use disorder, genetic testing and counseling, sexual assault/abuse, child abuse, sexually transmitted illness, pregnancy and birth control.

* I understand if I share my Mercyhealth MyChart ID and password with another person, that person may be able to view my or my child’s health information and health information about someone who has authorized me as a proxy.

* I agree that it is my responsibility to select a confidential password, to maintain my password in a secure manner, and to change my password if I believe it may have been compromised in any way.

* I understand that access to Mercyhealth MyChart is provided as a convenience to patients and Mercyhealth has the right to end access at any time.

* I understand that entries I make may become part of my child’s legal medical record.

* I understand that once information has been disclosed, it potentially may be re-disclosed by the proxy and the disclosed information may not be covered by federal privacy protections.

* I understand that designating a Mercyhealth MyChart proxy is voluntary. I am not required to designate a Mercyhealth MyChart proxy and I am not required to provide this authorization. I also understand that Mercyhealth does not condition any of my healthcare treatment, payment, enrollment or eligibility for benefits on whether I provide this authorization.

* I understand my revocations will not affect any disclosures that were made prior to processing the revocation.

* I understand that additional terms and conditions applicable to my use of Mercyhealth MyChart are set forth on the site and I agree to any and all current and future terms and conditions noted on the Mercyhealth MyChart site.

* I understand that my child will have the option to create his or her own Mercyhealth MyChart account once he or she reaches age 12. If my child chooses to do so, he or she will have full access to his or her health information and he or she will have the ability to send private messages to his or her providers.

** Please provide a copy of legal paperwork verifying this information if not already on file.