Child Proxy Form

Access to Your MyChart Record 

To sign up for access to the MyChart record of your child(ren) who is/are a patient(s) (s) , please complete both pages of this Child Proxy Form. Please note that MyChart will be accessed through your MyChart record. Completing this Form will establish a MyChart record for you and the Patient(s), if the Patient(s) do/does not already have a MyChart record.
Parent/Guardian Information:











Please note the following age range limitations for MyChart. These age range limitations do not affect your rights to access your child's medical record by other means.
  • If your child is age 10-17: You will be granted partial access to their MyChart record. (e.g., appointment scheduling, immunizations) until they reach the age of 18.
  • Once your child reaches age 18, you will no longer have access to their MyChart record unless and until you and the adult child complete an Adult MyChart Proxy Form.
Please provide the following information for each child: (All fields are required. If you have more than one child for whom you would like proxy access, please select the "Add another response" option.
Child Information:





MyChart Terms and Agreement By signing this Form, I acknowledge and understand that: 
  • The Patient's health information is protected under federal and state laws.
  • MyChart is a secure online source of confidential medical information. 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. If I share my MyChart ID and password with another person, that person may be able to view my or the Patient's health information.
  • MyChart contains selected, limited medical information from the medical record and that MyChart does not reflect the complete contents of the Patient's medical record.
  • My activities within MyChart are trackable and that entries I make may become part of the medical record.
  • Access to MyChart is provided by Shepherd Center as a convenience to its patients and that Shepherd Center has the right to deactivate access to MyChart at any time for any reason. I understand that use of MyChart is voluntary and I am not required to use MyChart or to authorize a MyChart proxy. However, I also understand that if this Form is not completed, Shepherd Center will not provide proxy access to MyChart.
  • Once information has been disclosed, it potentially may be re-disclosed and the disclosed information may not be covered by federal and/or state privacy protections.
  • Shepherd Center does not condition health care treatment, payment or other services on whether this Form is completed.
  • Once information is disclosed, it may be re-disclosed and may no longer be protected by federal or state privacy laws.
  • I can revoke the Proxy's access at any time by providing a written request for revocation to Shepherd Center. This revocation will not affect any disclosures that were made before the revocation request.
  • The Proxy may have access to the Patient's MyChart until the earlier of the following:
    • The Patient reaches age 18.
    • I request in writing that access be terminated
    • The Patient revokes the access.

Contact Information