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MyChart Proxy Access Authorization

Access to Your Child's MyChart Record


To request access to your child's MyChart record, please complete both pages of this Child Proxy Form and return it to the office of your child's provider or the address shown below.

Please note that your child's chart will be accessed through your own MyChart record. Completing this form will establish a MyChart record for you and your child.

Return forms to: UI Health HIM Department (MC 772), MyChart Proxy Request, 833 South Wood Street, Suite B-52, Chicago, IL 60612 or fax to 312.413.8014 or email to recordrequest@uic.edu
 

Access to Another Adult's MyChart Record


To request access to the MyChart record of an adolescent with diminished capacity or adult whose health care you help manage, please complete both pages of this Adult Proxy Form and return it to the office of the patient's provider or the address shown below. Please note that the patient's chart will be accessed through your MyChart record. Completing this form will establish a MyChart record for you and the patient.

Return forms to: UI Health HIM Department (MC 772), MyChart Proxy Request, 833 South Wood Street, Suite B-52, Chicago, IL 60612 or fax to 312.413.8014 or email to recordrequest@uic.edu