Medical Record No.
Please align patient label to the right
Proxy Form (Guardian Power of Attorney 12 and Over)
Guardian/ Power of Attorney Access to the Online MyChart Record of a Patient
Age 12 or Older
Requirements and Procedures
If a patient is 12 or over and does not have capacity to sign the authorization, the patient’s authorized representative such
as a legal guardian or a person with legal authority may sign and access the patient’s online MyChart. This request must
be accompanied by a copy of the legal paperwork verifying the authority of the patient’s personal representative (i.e.
birth certificate, court order, power of attorney for health care).
Requirements for accessing a patient’s record:
Ø Individual requesting access must have legal guardianship or other authorization to act on behalf of the patient
Ø Guardian/POA Access Authorization form must be completed and signed
Ø Appropriate Guardianship, Power of Attorney or other documentation must be provided
Ø Each individual requesting access must have his or her own MyChart account
Ø Should Guardianship or your authority to act on behalf of the patient be revoked or limited you are responsible to
report this information immediately to Ann & Robert H. Lurie Children’s Hospital of Chicago or your
independent physician practice
I understand that:
Ø I must have a MyChart account
Ø I must log in to MyChart with my own User ID & Password
Ø I must click on 'My Family’s Records' to access the patient's medical information
Ø I agree to abide by the terms and conditions of the MyChart site
Ø MyChart is not appropriate to be used in emergency situations.
Legal Guardian/POA access to a patient’s record is revoked when:
Ø MyChart access to the patient’s record will be revoked when/if Guardianship changes or other rights expire or
Ø Legal Guardian or patient access disputes cannot be resolved
Communications on behalf of the patient must be sent from the patient’s record; responses will be posted in the patient’s
record. MyChart e-mail alerts will be sent to the e-mail address entered in the patient’s record.
If you already have a MyChart account, you will receive a letter notifying you that access to the patient’s record is
available, typically 5-7 business days. You will be granted access to the record only after the Guardian/Power of
Attorney Access Authorization form and any other required documentation is received.
If you do not have a MyChart account, upon submitting your electronic request a MyChart Activation Letter with Access
Code and instructions will be mailed to you typically in 5-7 business days. Access to MyChart will be granted upon
Lurie Children’s or your independent physician practice receiving the completed Guardian/Power of Attorney Access
Authorization. If you do not activate your account within 60 days after receiving your MyChart Activation Letter, the
patient’s account will be inactivated.
Form 5230 Revised 10/16 HIM Approved 5/11
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