Name: | DOB: | MRN: | PCP:

Public Family Access Request

Complete this form to request family access to a patient's MyChart account. Enter requested information and click the SUBMIT button. Please allow two (2) business days for a response.

Parent/Legal Guardian Information  
Delegate Patient InformationHave you, the person requesting access to a family member, ever been a patient at Children's Colorado?
Patient?
Delegate MyChart InformationDo you, the person requesting access to family member, have an active Children's Hospital Colorado account?
MyChart Account
Subject InformationThe "Subject" refers to the individual whose MyChart account you would like to access. 
 
Relationship to Subject

If you select "Legal Guardian," Legal Guardianship papers must be on file be access can be granted.

Subject 2 Information - OptionalThe "Subject" refers to the individual whose MyChart account you would like to access. 
Relationship to Subject

If you select "Legal Guardian," Legal Guardianship papers must be on file be access can be granted.

 
Subject 3 Information - OptionalThe "Subject" refers to the individual whose MyChart account you would like to access. 
Relationship to Subject

If you select "Legal Guardian," Legal Guardianship papers must be on file be access can be granted.

 
Terms and ConditionsBy my signature below, I hereby affirm that...
By signing this proxy request, I understand that I am giving my permission...
Terms and Conditions