MyChart - Request to Access a Minor's Record

Use this form to request MyChart access to a minor. Enter information about the minor to whom you are requesting access as well as information about yourself. All fields are required.

MyChart is currently available only for patients at the Greenville, Lexington, Shreveport, Portland, Medford, Chicago, Salt Lake City, Twin Cities, Erie, Springfield, Boston, Philadelphia, Ohio, Spokane, St. Louis, Texas, Pasadena, Sacramento, and Honolulu locations. Patients at all other Shriners facilities should continue to use the HealtheLife Patient Portal.

Your Information:

First Name:

Last Name:

Date of Birth:

Phone:

Street Address:

City:

State:

ZIP:

Email:

Minor Information:

The person you are requesting MyChart access to.

First Name:

Last Name:

Date of Birth:

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.