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 Access Level Definition
0 - 12 Full Access All access to the patient's myBeaumontChart is permitted without the signing of an "Authorization for Disclosure of Patient Medical Information" form.
See "Access to view my child's medical information below".
12 - 18 Limited Access by Default (with option for Full Access) At age 12 parent/guardian access is automatically changed to Limited Access. Limited Access displays a patient's Allergies, Immunizations, as well as the ability to electronically schedule appointments. No authorization form is required for this default Limited Access. At the discretion of the treating provider, in conversation with the patient as well as the parent/guardian, the Limited Access can be changed to Full Access. At the age of 18, all access to the patient's myBeaumontChart (whether Limited or Full) automatically expires.
18+ Full Access with proper authorization Full Access to the patient's myBeaumontChart for a family member is permitted with consent of the patient and the signing of an "Authorization for Disclosure of Patient Medical Information" form.
Legal Guardianship - 18+ Full Access with proper documentation Full Access to the patient's myBeaumontChart is permitted with the submission of Legal Guardianship documents. Access to the patient's chart will expire at expiration of these documents and will need to be renewed.

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