My Health Connection Child Proxy Access Request Form
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2My Health Connection
Child Proxy Access Request Form
I am the legal parent/guardian of the child listed below. I understand that submitting this completed form allows me to act
as a substitute (a “proxy”) to get information about my child’s health. I understand that the information I access is
confidential and kept safe through a secure electronic system called “My Health Connection” (MHC) used by University
of Colorado Health (UCHealth). I agree to and will follow the terms of using MHC, which are available to review on the
MHC website.
Important Note:
Under the age of 14: Parents/guardians will have full access to all aspects of the child’s MHC account, including
appointments, medications, test results and more.
Ages 14-18: Parents/guardians will have limited access to the child’s MHC account. They will have the ability to
message the child’s provider(s), but they will not be able to view test results, appointments, etc. The 14-18 year
old child will have full access to their MHC account.
18 years or older: Parents/guardians will no longer have any access to the child’s MHC account, while the child
over 18 years of age will have full access to their MHC account. If the child elects to provide parent with adult
proxy access, an Adult Proxy Access Form must be completed.
Special needs: If a child is 14 years of age or older, with special needs and unable to manage their own health
care, the child’s parents/guardians are allowed to maintain full access to all aspects to the child’s MHC account.
This arrangement should be discussed with your child’s health care team.
Proxy Information:
Have you been a patient at University of Colorado Health (UCHealth)? Yes No
If yes, do you have an active UCHealth MHC account? Yes No
(Proxies must have a MHC account of their own in order to access their child’s MHC account.)
Parent/Legal Guardian (Proxy must provide copy of photo ID.)
Permanent Legal Guardian or Conservator (Proxy must provide copy of photo ID and attach copy of the Legal
Paperwork Appointing Guardianship or Conservatorship)
Durable Power of Attorney (DPOA) for Healthcare (Proxy must provide photo ID and copy of DPOA)
Confirmed on date: ____________ By: ________________________________ (UCHealth employee signature/title)
Please print clearly and complete all items.
PROXY:
PATIENT (Child):
Full Name
Full Name
Gender
Date of Birth
Med Record #
Date of Birth
SS#
Address
Address
City/State
Zip Code
City/State
Zip Code
Phone
E-mail
Phone
E-mail
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