Name: | DOB: | MRN: | PCP:
*PATIENT COPY*

Request for MyChart Access

MyChart offers an electronic option for parents and legal guardians to access care related information for their children, as well as an enhanced ability to communicate with health care providers at Rady Children’s Hospital-San Diego or its affiliates. Rady Children’s is now offering a mechanism for patients to receive telemedicine services (remote visits with providers) from the comfort of their home. A MyChart account will enable you to securely use the Internet to help manage and receive information about your child's health and to receive telemedicine services.

In order to provide telemedicine services (remote care) for your child(ren), you will need to establish a MyChart account. Please enter the requested information below and click the SUBMIT button.

Please allow three (3) business days for a response. Please note that the individual signing up for a MyChart account must be a parent or legal guardian of the patient.

By requesting this MyChart access, you agree that a Rady Children’s electronic health record will be created for your child/children. This electronic record is required in order for Rady Children’s to activate a MyChart account. This electronic health record will remain in effect even if you ultimately decide not to pursue care and/or treatment for your child at Rady Children’s.

Parent/Legal Guardian Information
 
 
Existing MyChart Account
Do you have an active Rady Children's Hospital MyChart account for yourself or another child under your care?
Existing MyChart Account
Patient Information
The "Patient" refers to the individual whose MyChart account you would like to access.
 
 
Relationship to Patient

If you select "Legal Guardian," the appropriate papers must be on file be access can be granted.

Patient 2 Information - Optional
The "Patient" refers to the individual whose MyChart account you would like to access.
 
Relationship to Patient

If you select "Legal Guardian," the appropriate papers must be on file be access can be granted.

 
Patient 3 Information - Optional
The "Patient" refers to the individual whose MyChart account you would like to access.
 
Relationship to Patient

If you select "Legal Guardian," the appropriate papers must be on file be access can be granted.

 
Attestation
By signing below, I certify that I am the parent or the legal guardian for the patient(s) named above, and that the information I have provided is true and correct. If additional information is required, I am willing to provide such documents as requested by Rady Children's Hospital-San Diego and its affiliates.
Confirmation