Name: | DOB: | MRN: | PCP:

Child Proxy/Release of Information Form

A proxy can see the MyHealth record of a Harris Health patient. You may ask to see a child’s health information if you are the parent or legal guardian of a child under the age of 18. The right to get health information for children ages 13 to 17 may be restricted with a higher level of privacy.

Once your child turns 18, you may no longer be able to see your child’s MyHealth record.
To set up proxy access to your child’s medical record, please submit the request below. In addition to submitting your request, you may also need to email proof of the relationship you select on the form below to mychartproxy@harrishealth.
Allow 7 days to complete the request.

Once completed, you will receive a MyHealth Activation Email. Please activate the account. Your proxy access to your child’s medical record will appear in "Personalize" the next time you log in to MyHealth/MyChart.
Please note that only certain information from the child’s chart will be seen in the MyHealth record.

Parent/Legal Guardian Information:

Child's Information: