Adolescent Access Authorization Form printable pdf download

MyHealth Online - Adolescent Access

Adolescent access for MyHealth Online allows an adolescent patient between the ages of 13 to 18 to view

components of their medical record and communicate with their physician's office regarding non-urgent

matters. The parent or legal guardian will also be able to view a limited portion of the adolescent's medical

record and communicate with the physician's office. In order to obtain access, Adolescent patients may sign up

for access only during an office visit. Parents who do not already have proxy access will need to sign the form

at the office.

Adolescent proxy access is terminated when the parent/legal guardian makes a written or online request to

terminate access. At age 18 the patient will have full control of their MyHealth Online account and the

parent/legal guardian access will be discontinued. Beyond the age of 18 the patient may still grant parent/legal

guardian access by requesting Adult Proxy access.

Adolescent Access and Adolescent Proxy Terms and Conditions:



The parent/legal guardian must complete and sign the attached Adolescent Proxy Authorization

Form. Please call the number listed on the Atrius Health Practice Location Information Sheet if you

need further assistance.



Important: You can print and fill-out this form at home but it will only be accepted if delivered to our

office in person.



Each parent/legal guardian requesting access must have an active MyHealth Online account but,

does not need to be an Atrius Health patient.



Adolescent access can be terminated by the parent/legal guardian at anytime online or by written

request.



For existing Pediatric Proxy MyHealth accounts, the parent/legal guardians access will remain in

MyHealth when the child turns 13, but the access will be limited as below.

MyHealth Access will enable you to:

Adolescents:

Parents / Legal Guardians:



View growth charts, immunizations, allergies

View growth charts, immunizations and

and medications

allergies



Communicate with your physician’s office on

Communicate with the physician’s office on

non-urgent issues



View lab results



Request, schedule, cancel appointments

Schedule appointments (but cannot cancel or



review past/future appointments)

View appointment history



View School/Camp forms and letters



Additional features may be enabled over time

Adolescent Access Authorization Form

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