MyChart - Request to Access a Minor's Record

Welcome! OU Health is pleased to offer this online request service for access to a patient's MyChart record. Please note that this patient's chart will be accessed through your MyChart record. Please fill in all fields, as they are required to verify your MyChart membership.

Once a patient reaches age 18, you will be required to reestablish a proxy account with the patient’s approval.

Your Information:

First Name:

Last Name:

Date of Birth:

Legal Sex:

Phone:

Street Address:

City:

State:

ZIP:

Minor's Information:

First Name:

Last Name:

Date of Birth:

Legal Sex:

Phone:

Street Address:

City:

State:

ZIP:

Minor's Relationship to You:

If other, please specify:

Right to access:

I certify that I have the legal right to this minor's medical information.

By submitting this request, I acknowledge and agree that:

1. I will be using my own MyChart account to access the Child’s MyChart account.
2. I will comply with the MyChart Terms and Conditions for use of MyChart, available upon activation of a MyChart account.
3. I will keep my password confidential and not share this information with anyone.
4. I must have parental rights or permanent legal guardianship rights to access this Child’s record.
5.There are no court orders in effect limiting or denying my access to this Child’s medical records and/ or information.
6. There are age range limitations for MyChart. These age range limitations do not affect any legal right I have to access the Child’s record by other means. I can request a paper copy of the Child’s record by contacting the Health Information Management department.
7. I may revoke this authorization at any time directly in MyChart.
8. I have a right to receive a copy of this authorization.
9. If my parental or legal guardianship rights change, I will notify OU Health.