Name: | DOB: | MRN: | PCP:

MyChart Family Access Request

Complete this form to request family access to a UTMB patient's MyChart account. Enter requested information and click the SUBMIT button. Please allow two (2) business days for a response.

Delegate Identity
 
Delegate Contact Information
 
Delegate Patient Information
Has delegate ever been a patient at a UTMB Health facility?
UTMB Patient
Delegate MyChart Information
Does the delegate have an active UTMB MyChart account?
MyChart Account
Instructions
Specify the family member(s) to which you would like to be granted access.

For each, specify a type of Family Access. Please note that for all types of family access, the patient's MyChart will be accessed through the delegate's MyChart account.

Please indicate which of the following best describes the proxy access requested.

  • Adult - Adult (Access to another adult's MyChart record)
    Authorization for family access to an adult patient's account is valid until revoked by the patient.
  • Adult - Child (Access to your minor child's MyChart record)
    Please note the following age range limitations for MyChart:
    If your child is age 0-13 you will be granted full access to your child's MyChart record.
    If your child is age 14-18 you will be granted partial access to your child's MyChart record.
  • Adult - Special Needs Minor (Access to your minor child's MyChart record)
    Please note the following age range limitations for MyChart:
    If your child is age 0-18 and has special medical needs documented, you will be granted full access to your child’s MyChart record.

These age range limitations do not affect any legal right you have to access your child's record by other means.
Once your child reaches age 18, you will no longer have access to their MyChart record.
Subject 1 (Required) Add Subject 2 Add Subject 3 Add Subject 4 Add Subject 5
Subject Information - Required
Family Access Type
 
 
Optional Additional Subject 1 Information
Family Access Type
 
 
Optional Additional Subject 2 Information
Family Access Type
 
 
Optional Additional Subject 3 Information
Family Access Type
 
 
Optional Additional Subject 4 Information
Family Access Type
 
 
Terms and Conditions
By my signature below, I hereby affirm that I am the patient (subject) identified above and I am agreeing to allow the above individual family access to my MyChart account. I affirm that I have read and agree to be bound by the stated Terms and Conditions. I understand that I may be subject to penalties under law for submitting false or misleading information in connection with this application to access this MyChart service.
By signing this proxy request, I understand that I am giving my permission for UTMB Health to disclose my protected health information (PHI) through MyChart to my proxy. Information includes, but is not limited to: health summary, current problem list, current medications, lab results, appointment information.

A comprehensive list of information available through MyChart is available at: http://mychart.utmb.edu.

The information available to my proxy may include information relating to: (1) Acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection, (2) treatment for drug or alcohol abuse, (3) sexually transmitted diseases, or (4) mental or behavioral health or psychiatric care.

This proxy request is effective until my MyChart account is inactivated or proxy access is revoked and includes records that were created or existing on or before the date this form was signed, as well as records that are created after the date this form is signed.

I understand that I may revoke proxy access at any time: 1) through changing MyChart Family Access Settings or 2) notifying UTMB Health in writing to the Health Information Management Department, 301 University Blvd, Galveston, Texas 77555-0782 or by fax at 409.772.5101 of my intent to revoke an individual’s proxy access.

I understand that such a revocation will not have any effect on any information already released to my proxy.

If neither federal nor Texas privacy law apply to the recipient of the information, I understand that the information disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by federal or Texas privacy laws.

Proxy request is voluntary and I may refuse to sign this form. I understand that I am not required to sign this Authorization Form in exchange for the receiving treatment from UTMB Health.

Any documents, if any, I have provided to support of my right to access the patient’s protected health information, are true and correct copies and are the most recent documents related to this matter. When my legal authority to act on behalf of the patient has been inactivated, revoked, terminated, or expired, I must immediately notify UTMB Health in writing of the change in authority and mail it to the Health Information Management Department, 301 University Blvd, Galveston, Texas 77555-0782 or by fax at 409.772.5101.

Please type your complete legal name (or parent/delegate name for minor patients)