MyChart -

Parent/Legal Guardian Information

First Name

Middle Name

Last Name

Date of Birth

Address

City

State

Zip Code

Primary Phone

Other Phone

Email Address

Activation Code Delivery

How would you like to receive your activation code?

Method

SMS Text MessageE-MailVerbally Over the Phone

Delegate Patient Information

Have you, the person requesting access to a family member, ever been a patient at Children's Colorado?

Patient?

YesNo

Delegate MyChart Information

Do you, the person requesting access to family member, have an active Children's Hospital Colorado account?

MyChart Account

YesNo

Subject Information

The "Subject" refers to the individual whose MyChart account you would like to access.

First Name

Middle Name

Last Name

Date of Birth

Previous or Other Names Used

Street

City

State

Zip Code

Relationship to Subject

Birth ParentSelfLegal GuardianAdoptive Parent

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

Subject 2 Information - Optional

The "Subject" refers to the individual whose MyChart account you would like to access.

First Name

Middle Name

Last Name

Date of Birth

Previous or Other Names Used

Street

City

State

Zip Code

Relationship to Subject

Birth ParentSelfLegal GuardianAdoptive Parent

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

Subject 3 Information - Optional

The "Subject" refers to the individual whose MyChart account you would like to access.

First Name

Middle Name

Last Name

Date of Birth

Previous or Other Names Used

Street

City

State

Zip Code

Relationship to Subject

Birth ParentSelfLegal GuardianAdoptive Parent

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

Terms and Conditions

By clicking I Accept, I hereby affirm that the information provided in this form is accurate and representative of me and not another individual.

Terms

I Accept

Public Family Access Request