MyChart - MyChart Account Update Request: Add Child(ren)

Thank you for your interest in MyChart at Cincinnati Children's. To add a child to your existing account, please complete the form below. We will contact you by phone if we have any questions regarding the information provided.

IMPORTANT REQUIREMENTS:

The patient must be an established patient at Cincinnati Children's in order to request a MyChart account online.

The patient must be between the ages of 0 and 17.

This form can also be used to request access to patients 18 and over with diminished capacity. Appropriate proof of ongoing legal guardianship is required.

Unfortunately, at this time, MyChart access cannot be granted to foster parents, social workers, or other family members.

Once your request has been approved, we will send you an email confirmation within 7 business days after your account is updated.

Step 1 | TELL US ABOUT YOU:

Today's Date:

First Name:

Middle Initial:

Last Name:

Your Date of Birth:

Street Address:

City:

State:

Zip Code:

Mobile Phone (xxx-xxx-xxxx):

Email Address*:

*A valid email address is required to request a MyChart account.

Current Login ID:

Name(s) of child(ren) to whom you already have MyChart Access:

Step 2 | CHILD/PATIENT INFORMATION:

Please provide information for the child for whom you are requesting access. It is not necessary to provide the name(s) and information for children to whom you already have access.

Patient's First Name:

Patient's Middle Name:

Patient's Last Name:

Sex Assigned at Birth:

Patient's Date of Birth:

Your relationship to the child:

If other, please specify:

If the patient is 18 years old or older:

Does your child have diminished capacity (e.g., cognitive or developmental delay)?

No Yes Patient is under 18

Click here to securely upload proof of legal guardianship (if applicable)

IMPORTANT: Proof of continued legal guardianship is required for MyChart access after the patient turns 18.

ADDITIONAL CHILD/PATIENT INFORMATION:

Please provide information for the child for whom you are requesting access. It is not necessary to provide the name(s) and information for children to whom you already have access.

Patient's First Name:

Patient's Middle Name:

Patient's Last Name:

Sex Assigned at Birth:

Patient's Date of Birth:

Your relationship to the child:

If other, please specify:

If the patient is 18 years old or older:

Does your child have diminished capacity (e.g., cognitive or developmental delay)?

No Yes Patient is under 18

Step 3 | TEXT MESSAGE CONSENT:

Text messages related to your relationship with Cincinnati Children's, including updates related to your visits, MyChart account, one-time passcode, billing notifications, prescription reminders, and care management will be sent to the phone number above. Message and data rates may apply. Message frequency may vary. For help text HELP and text STOP to opt out of notifications from a specific short code. Messages will be sent from "831110" Please review Terms and Conditions and privacy policy.

Please select (It will turn blue when clicked)

YES, I would like to receive text message notifications. NO, I would not like to receive text message notifications.

Step 4 | PLEASE READ AND SIGN THIS FORM:

You must read, understand, and agree to the terms described in our Cincinnati Children's Terms and Conditions of Use posted on the MyChart website before your account can be updated. Violations of these terms may result in loss of access to MyChart. Once you have read this document, please sign this form below.

Click the statement to the right to sign this form electronically (It will turn blue when clicked)

YES, I sign this form electronically and certify that I am the parent or primary caregiver of the child(ren) or patient listed above and that all information I have provided is correct. By signing this form, I acknowledge that I have read, understand, and agree to abide by the Terms and Conditions of Use posted on the MyChart website. I understand that a violation of such terms may result in loss of access to MyChart.