Name: | DOB: | MRN: | PCP:

Request Access to a Minor's Record

Thank you for your interest in MyChart, a web portal that provides you quick and secure online access to your child's health information at Upstate Medical University. To sign up for access to your child's Upstate MyChart record, please complete and submit the following form for approval. Once your request has been approved, we will email your activation code within 2 business days. If you already have an active Upstate MyChart, you will be notified via email when access has been granted. We will contact you if we have any questions regarding your information. Please note that access to a child’s record through MyChart can only be granted to a parent or legal guardian.

Please note the limitations below for Upstate MyChart based on your child's age. To request a paper copy of your child's records, contact the provider's office directly.

If your child is 11 years old or younger, you will be granted full access to their Upstate MyChart record.

Once your child reaches age 12, they will be able to access their own Upstate MyChart record and your proxy access will become limited. At this point, you will only have access to scheduling, demographics, and billing information.

Once your child reaches age 18, you will no longer have access to their Upstate MyChart record.

Minor's Information:

Your Information:

MyChart Information: