MyChart Enrollment Forms

MyChart offers patients personalized and secure on-line access their medical records. It provides a secure method for patients to help manage and receive information about their health.

MyChart Proxy access provides an individual who is authorized access to a patient’s records or to perform activities on their behalf (e.g. parent, guardian, patient representative, healthcare surrogate, etc.).

To establish MyChart Proxy access, review and fill out the forms required based on the MyChart Proxy access needed and return them to your Franciscan Physician Network provider office or Franciscan Health hospital medical records department for setup.

Adolescent Patient MyChart Access

(patients 12 to 17 years + 364 days)

• Allows an adolescent to have access to a MyChart account
• Both patient and parent/guardian sign the same form
• Patient AND Parent/Guardian Form: MyChart Informed Consent for Adolescent Patients Form

Child Patient - Parent/Guardian Proxy Access

(patients 0 to 11 years + 364 days)

• Allows full access to the patient’s information
• Patient Form: None Required
• Proxy Form: MyChart Proxy Record Request and Acknowledgement of Terms and Conditions

Adolescent Patient - Parent\Guardian Proxy Access – Limited Access

(patients 12 years to 17 years + 364 days)

*Note: New regulatory requirements impacting Proxy Access for Adolescents go into effect on 11/2/2020. Parents/guardians with Proxy Access prior to 11/2/2020 will continue with Limited Access and will need to complete the forms found in the ‘Adolescent Patient - Parent\Guardian Proxy Access – Full Access’ section if requesting full access to the information.

• Allows for limited access to information like allergies and immunizations and provides ability to schedule appointments.
• Patient Form: None Required
• Proxy Form: MyChart Proxy Record Request and Acknowledgement of Terms and Conditions
• MyChart Terms and Conditions

Adolescent Patient - Parent\Guardian Proxy Access – Full Access

(patients 12 years to 17 years + 364 days)

• Allows full access to the patient’s information
• Patient Form:MyChart Record Parent/Guardian Proxy Release of Information Authorization (To be completed by the Patient Age 12 – 18)
• Proxy Form: MyChart Proxy Record Request and Acknowledgement of Terms and Conditions by Parent/Guardian for Adolescent – Full Access
• MyChart Terms and Conditions

Adult Patient - Proxy Access

• Allows full access to the patient’s information
• Patient Form:MyChart Record Adult Proxy Release of Information Authorization
• Proxy Form: MyChart Proxy Record Request and Acknowledgement of Terms and Conditions
• MyChart Terms and Conditions

Adult/Adolescent Patient without Decisional Capacity – Proxy Access

• Allows full access to the patient’s information
• Patient Form:None Required
• Proxy Form: MyChart Proxy Record Request and Acknowledgement of Terms and Conditions
• MyChart Terms and Conditions

Adult/Adolescent Patient - Patient Representative or Healthcare Surrogate Proxy Access

• Allows full access to the patient’s information
• Used for Power of Attorney (POA) guardian, healthcare representative, or surrogate
• Patient Form:None Required
• Proxy Form: MyChart Proxy Record Request and Acknowledgement of Terms and Conditions
• MyChart Terms and Conditions