Name: | DOB: | MRN: | PCP:

Sign up for access to your child's record

Introducing Cook Children’s MyChart, the new and improved online patient portal. This easy-to-use tool is accessible anywhere and provides you with quick and secure access to your child’s health information at Cook Children’s. To sign up for access to your child's Cook Children's MyChart record, please complete and submit the following form for approval. Once your request has been approved, we will email your activation code within seven business days. We will contact you if we have any questions regarding your information. Please note that access to a child's record through MyChart can only be granted to a parent or legally authorized representative.

Please note there are limitations for access to your child's MyChart account based on your child's age. Please see below for details.

Parent/Legally Authorized Representative Information

Date of birth of the parent or legally authorized representative.

Requesting access for
  

Child's Information

Second Child's Information

Third Child's Information

***Please Read and Certify***

By clicking submit I certify that: I am the birth/adoptive parent or legally authorized representative of the child (and/or children) listed above, and that all information I have provided is correct. By signing this form, I also agree to the Terms and Conditions for use of MyChart, which can be found on the MyChart website. I hereby request access to my child's (and/or children's) online record.

Please note the limitations below for Cook Children's MyChart based on your child's age. These age limitations do not affect any legal right you have to access your child's records by other means. To request a paper copy of your child's records, contact Cook Children's Release of Information Department.

If your child is 17 years old or younger, you will be granted full access to their Cook Children's MyChart record.

Once your child reaches age 14, they will be able to access their own Cook Children's MyChart record pending the approval of the parent/legally authorized representative and the provider.

Once your child reaches age 18, you will no longer have access to his/her Cook Children's MyChart record, unless express consent is given by the patient.

If you are a patient over the age of 18 requesting access to your own record, please contact your provider's office directly.