MyChart - Request to Access a Minor's Record

Use this form to request MyChart access to a minor. Enter information about the minor to whom you are requesting access as well as information about yourself. All fields are required.

Your Information:

First Name:

Last Name:

Date of Birth:

Legal Sex:

Phone:

Street Address:

City:

State:

ZIP:

Email:

Minor Information:

The person you are requesting MyChart access to.

First Name:

Last Name:

Legal Sex:

Date of Birth:

Street Address:

Minor's Relationship to You:

If other, please specify:

Please specify the most recent ordering clinician of the minor’s clonoSEQ test:

Please specify the most recent date (month/ year) of the minor’s clonoSEQ test:

Right to access:

I certify that I have the legal rights to access this information and that I can provide any necessary information to validate my right to access this information, if necessary.