Middle
MYCHART ENROLLMENT FORM
Patient Information Name:
Last First Middle
Date of Birth
Address:
Street StateCity Zip
Email Address:
Person Authorized to have MyChart access
Name:
Last First
StateCity Zip
Mother Father Legal Guardian Residential Grandparent
I am authorized to access information on the above patient via MyChart according to Akron Children's Hospital MyChart Terms and Conditions.
I am authorized to access information on the above patient via MyChart according to Akron Children's Hospital MyChart Terms and Conditions.
(For office use only. Provider signature is required to
confirm the patient has diminished capacity)
FM00142
Rev. 07/21
*MYCHART*
MyChart Enrollment Form
Page 1 of 1
(Place patient label here if blank)
Date of Birth
Provider Signature Date Time
Signature Date Time
Mother Father Legal
Guardian Durable Power of Attorney for Healthcare (DPOA)
Signature Date Time
I am the Patient,
and I am requesting access to my own MyChart account.
Address:
Email Address:
Phone:
Legal Guardian accessing Minor Patient (ages 0-17)
Please Check your relationship to the patient (choose one):
• Legal Guardian: MUST have a copy of court order supporting legal guardianship
• Residential Grandparent: must provide either a Grandparent Power of Attorney or Caretaker Authorization Affidavit
OPTION #3
Accessing MyChart of a Patient with diminished capacity
Please Check your relationship to the patient (choose one):
• Legal Guardian: MUST have a copy of court order supporting legal guardianship
• Durable Power of Attorney for Healthcare: MUST have a copy of the DPOA
Please email completed form
with Photo ID
to:
records@akronchildrens.org,
return to Office Staff
or mail to:
Akron Children's Hospital
Health Information Mgmt - MyChart
One Perkins Square Akron, Ohio 44308-1062
City
CHOOSE ONE
OPTION #1
OPTION #2
click to sign
signature
click to edit
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click to sign
signature
click to edit
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click to sign
signature
click to edit
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