Request MyChart Family Access


You may request access to another patient's MyChart account to view health information. Please select the appropriate authorization form below, print and return the completed form to this address.

Health Information Management Identity - Data Integrity

N17W24100 Riverwood Drive, Suite 200

Waukesha, WI 53188

Fax:262-544-9489

Contact the Help Desk at 1-877-873-6305 with any questions


Adult Requesting Access to Another Adult (18 years of age and older):

To request access to view another adult patient's MyChart account print and fill out the MyChart Proxy Access Sign-Up form below. In addition to the form below the patient's signed consent MyChart Proxy Authorization form will be required before access will be granted. You will have access to everything the patient would have access to in their own account. Please keep in mind that the patient can revoke your access at any time, if these so choose.


MyChart Proxy Access Sign-Up Form
MyChart Proxy Authorization Release of Information Form (patient signs)

Parent Requesting Access to Minor age 0-11:

As the parent or legal guardian, you will be granted full access to your child's MyChart account. To request access, print and complete the following form.


MyChart Proxy Access Sign-Up Form

Parent Request Access to Minor age 12-17:

Under State and Federal law, there are certain types of medical information that the parent or legal guardian of a child age 12 to 17 may not view without the child's consent. Because of these requirements, a parent or legal guardian will have limited access to a child's account. The access includes allergies and immunizations on file. To gain full access, the child must print and fill out the MyChart Proxy Authorization Release of Information Form and the parent or legal guardian must print and fill out the MyChart Proxy Access form. This access expires once the child turns 18 unless access is previously revoked by the child.


MyChart Proxy Authorization Release of Information Form (patient signs)
MyChart Proxy Access Sign-Up Form