Name: | DOB: | MRN: | PCP:

Activation Code and Child Proxy Request

All fields with a * are required.
 

You must be 18 years and older to request an activation code online. If you are under 18, please speak with your doctor's office.

To sign up for access to your child's MyChart record, please complete and submit this Activation Code (Non-UR Medicine) and Child Proxy Access form. Your child's chart will be accessed through your MyChart record. We will mail your activation code to your home address within seven business days of receiving your information. We will contact you if we have any questions regarding your information.

Due to New York State requirements, your child's permission (consent) will be required beginning at age 12 for you to continue to have full access to their electronic medical information. Therefore, the day before he/she turns 12 years of age, your access will automatically be transitioned to a limited view of your child's MyChart. A limited view will allow you to see a small subset of information (allergies, immunizations, letters, and flowsheets); full access to your child's chart may be reinstated upon receipt of your child's consent. These age limitations do not affect any legal right you have to access your child's record by other means. To request a copy of your child's record other than through MyChart, please contact the Health Information Management (HIM) office at Strong or Highland, or your child's doctor or clinic.

I understand that Strong, Highland, and their doctors can revoke access to MyChart (for patients and their proxies) at any time for any reason.

Parent/Legal Guardian Information

If you do not know if you have seen any UR Medicine Physicians, please provide your Primary Care Physician.

  

Child's Information

Child's Information

Child's Information

 

***Please Read and Certify***

I certify that: I am the birth/adoptive parent or legal guardian of the child (and/or children) listed above, and that all information I have provided is correct. By signing this form, I also agree to the Terms and Conditions for use of MyChart, which can be found on the MyChart website. I hereby request access to my child's (and/or children's) online record.

I Certify*: