Name: | DOB: | MRN: | PCP:

SmileGeneration MyChart Proxy Access Request and Consent

Proxy Access allows parents, spouses, adult children, and others to be granted access to a patient’s personal health record in SmileGeneration MyChart ("MyChart").

Please note that for all types of proxy access, you must access the patient’s account to which you have proxy access using your own MyChart login and password. If you do not have a MyChart account, you will receive an access code to create an account upon approval of your proxy request.

Please review the information below regarding MyChart Proxy Access and complete the form below.


Adult-Child (Access to a minor child's MyChart record):

  • If your child is age 0-11: You will be granted full access to your child's MyChart information.
  • If your child is age 12-17: Due to federal and state minor consent laws, you may not have full access to your minor child’s MyChart information.
  • Once your child is 18 or older, you will no longer have access to your child's MyChart information without his/her written consent.
  • If you are not the birth parent of the child, consent from the child's legal guardian must be obtained in order to be granted proxy access.

Adult-Adult (Access to an adult’s MyChart record):

  • If the adult patient has an active MyChart account or will establish their own MyChart account, you do not need to complete the Proxy Access Request form below. The patient has the ability to share his/her record with you from within their own MyChart account. Please click here for instructions
  • For access to an adult patient’s record who chooses not to have their own MyChart account, complete the Proxy Access Request Form below; print this HIPAA Authorization to Use or Disclose PHI Form; have the patient complete, sign and submit it to their provider’s office.
  • If the adult patient is not their own legal guardian, complete the Proxy Access Request form below. You will need to provide legal documentation to validate that you have the proper authority to be granted access to the patient’s record. Legal documentation includes documents such as a court order or an appropriate power of attorney.
  • The patient has the right to revoke proxy access from any individual he or she has designated as a proxy, at any time.

Submission Instructions:

Complete the proxy request form online and bring proper photo identification along with any additional required legal documentation to your provider’s office. Additional information may be requested from you.

Upon our receipt of this online form, your access request will be processed within approximately 72 hours. A staff member will review your information, and validate documentation pertaining to the patient and you. All documents must be presented in person, together with valid government-issued photo identification in order to verify your identity and legal authority.

In some circumstances, you may receive an access code for provisional proxy access to the patient’s MyChart account. Full proxy access to the patient’s MyChart account will only be granted upon in-person verification of your identity and legal authority.



Proxy Requestor Information:

Patient Information:

*Requestor's Relationship to Patient :

User Acknowledgement of Terms and Conditions for Use of MyChart:

I am requesting proxy access to MyChart, which contains the online health information for another person. By signing below, I represent that I have the legal right to access the information contained in the above named patient's clinical record and have read and agree to abide by the MyChart Terms and Conditions of use.


*I certify: