Name: | DOB: | MRN: | PCP:

Request an Activation Code: Adult to Child

Completing this form allows someone else ("Proxy") 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 (when applicable) and Proxy must agree and comply with the terms and conditions on the MYchart web page, and this document.

Proxy:
I acknowledge and agree that:

* I have parental rights or legal guardianship rights to access this Patient's record.
* I have not been denied periods of physical placement with the Patient and there are no court orders or restraining orders in effect limiting my access to this Patient's medical records and/or information.
* I will be using my own MYchart account at the Organizations to access the Patient's 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.
* Communications on behalf of the Patient through MYchart must be sent from the Patient's record and responses will be received in the Patient's record. For a child age 0-13, MYchart alerts will be sent to the e-mail address entered under Proxy Information. For a child age 13-17, MYchart e-mail alerts will be sent to the email addresses provided by both the Proxy and Patient.

 
Patient Information
 
Proxy 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.