Name: | DOB: | MRN: | PCP:

Request an Activation Code: Teen

Completing this form allows a "teen" Patient (13 years old or older) having parental consent to be able to access portions of the Patient's protected health information maintained by Children's Healthcare of Atlanta, Inc. and/or any of their electronic medical record affiliates (the "Organizations") through MYchart. The Patient must agree and comply with the terms and conditions on the MYchart web page, and this document.

Patient:
I acknowledge and agree that:

* I will be using my own MYchart account at the Organizations to access the Patient's MYchart account.
* I have obtained consent from a parent or legal guardian to establish my own MYchart account.
* I will comply with the terms and conditions on the MYchart web page and this document.
* I will keep my password confidential and not share this information with anyone.

 
Patient Information
 
Parent Information
By typing my name in the space labeled "Signature" below (which shall constitute my signature), I hereby certify that the information furnished above is true and complete. I acknowledge that the name indicated above is my current full legal name and I am authorized to sign this form.