Name: | DOB: | MRN: | PCP:

Sign up for MyCookChildren’s Portal access

Welcome to MyCookChildren’s. This easy-to-use tool can be accessed anywhere and gives you quick and secure access to your/your child’s information. To sign up for access to MyCookChildren’s Portal, please fill out and submit the form below for approval.

Once your request is approved, we will email you an activation code within seven business days. We will reach out to you if we have any questions about your information. Access to a child's information through MyCookChildren’s can only be granted to a parent or legally authorized representative. Your ability to access to your child's information will vary based on the child's age. Please see below for details.

Individual Requesting Access
Enter the following information for the individual requesting access.

Enter your Cook Children's Health Plan Member ID, if applicable. If you are requesting acces your child’s information, your child’s member ID will be entered below.

Reason for requesting access:*

Select all that apply.

If you are requesting access to a child's record, please fill out the rest of the form. If you only request access for yourself, you may submit the form below.

First Child’s Information
Enter the following information for the first child you are requesting access for (if applicable).
Second Child’s Information
Enter the following information for the second child you are requesting access for (if applicable).
Third Child’s Information
Enter the following information for the third child you are requesting access for (if applicable).
Fourth Child’s Information
Enter the following information for the fourth child you are requesting access for (if applicable).
Fifth Child’s Information
Enter the following information for the fifth child you are requesting access for (if applicable).
Please Read and Certify
By clicking submit I certify that: I am a patient or Health Plan member or the parent or legally authorized representative of the patient(s) or Health Plan member(s) listed above. All the information I have provided is correct. By signing this form, I also agree to the Terms and Conditions for use of MyCookChildren’s, which can be found on the MyCookchildren’s website. I hereby request access to my/my child's (and/or children's) online record(s).

Please note that access to MyCookChildren’s may be limited based on your child's age. If your child is 17 years old or younger, you will be granted full access to their MyCookChildren’s record. Once your child reaches age 14, they will be able to access their own MyCookChildren’s record, if approved by their parent/legally authorized representative and the provider. Once your child reaches age 18, you will no longer have access to their MyCookChildren’s record, unless express consent is given by the child or you are appointed as your adult child’s legally authorized representative.