Authorization for Parental Access to My Kid's Chart Portal

Authorization for Parental Access to My Kid's Chart Patient Portal and Permission to speak with

Ages 18 and older
Patient Name

First NameLast Name
DOB

MonthDayYear
Date
Today's date

MonthDayYear
Date
I AUTHORIZE the following Parents/Guardians to have access to my patient portal

First NameLast Name
First NameLast Name
Signature

Clear
I REVOKE the following Parents/Guardians to have access to my patient portal

First NameLast Name
Signature

Clear
Should be Empty:

Authorization for Parental Access to My Kid's Chart Patient Portal and Permission to speak with