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Request Access to Another Patient's Health Record (Proxy)

Would you like to gain access to your child's MyChart health record? If you already have a MyChart Account you can log in and request with our online form. Select the 'Personalize' option under the 'Settings' menu. Otherwise, download this PDF form and either drop it off in person at your child's health care provider's office or mail it to the Rush Copley Health Information Management office (see form for the office's contact information). Please note: Access in MyChart is only available for children under 12 years of age.

Online Child Proxy Request Form
Child Proxy Request Form (PDF) Child Proxy Request Form (PDF)

Would you like to gain access to another adult's MyChart health record? Download this PDF form and either drop it off in person at the patient's health care provider's office or mail it to the Rush Copley Health Information Management office (see form for the office's contact information). Please note: The adult patient must provide signed consent, or you will need to provide documentation that you, the proxy, are the patient's legal guardian or hold durable power of attorney for the patient's health care.

Adult Proxy Request Form (PDF) Adult Proxy Request Form (PDF)