Name: | DOB: | MRN: | PCP:

Child Proxy/Release of Information Form

This form is intended only for parents/guardian's who are not patients at Harris Health. If you are a parent/guardian and have MyHealth access to your own patient record, please complete this this form (you will need to log in before completing the form). If you are a patient at Harris Health and do not have MyHealth access, please call our MyHealth help desk at 713-634-1661 to get set up with an account yourself before requesting access to a child/minor.

A proxy can see the MyHealth record of a Harris Health patient other than you. 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.

Access to a Child’s MyHealth Record

To ask to see the MyHealth record of a child over whom you have legal guardianship, please fill out this form. In addition to completing this form you may also need to email proof of the relationship you select in the form below to mychartproxy@harrishealth. Please note that only certain information from the child’s chart will be seen in the MyHealth record.

Once your child turns 18, you will no longer be able to see your child’s MyHealth record.

Parent/Legal Guardian Information:

Child's Information: