Name: | DOB: | MRN: | PCP:

Request for Child Proxy Access

Welcome! Beaumont Health is pleased to offer this online request service to request electronic access of your child's medical information. You must be the child's parent or legal guardian to access the record. Once a child turns 18, access is automatically revoked.

Age 0-12: All access to the patient's myBeaumontChart is permitted without the signing of an "Authorization for Disclosure of Patient Medical Information" form.

Age 12-18: It is the physician's discretion to limit access to patient between the ages of 12 and 18. A physician could determine that limited or full access is permitted. Limited access is restricted to only a patient's Allergies, Immunizations, as well as the ability to electronically schedule appointments. Otherwise, full access to the patient's myBeaumontChart is permitted. No authorization form is required for access. At the age of 18, all access, whether it is limited or full, to the patient's myBeaumontChart automatically expires.

By clicking Submit, I certify that I am the parent or legal guardian of the child listed.