Minor Patient Portal Access Request Form
Request portal access for a minor patient by providing your contact details, the minor’s information, and the access details needed to review the request.
Requesting Parent or Guardian Information
Full Name
*
First Name
Middle Name
Last Name
Relationship to Minor
*
Please Select
Mother
Father
Legal Guardian
Step Parent
Grandparent
Other
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Minor Patient Information
Minor Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Identifier
Access Request Details
Requester's Relationship to the Minor
*
Please Select
Parent
Legal Guardian
Step-Parent
Foster Parent
Grandparent
Other Relative
Other
Reason for Requesting Portal Access
*
Requested Access Level
*
Please Select
View only
View and download records
View and message care team
Full portal access permitted for minor records
Other
Submit Request
Should be Empty: