Patient Portal -

Self or Parent/Legal Guardian Information

Requesting Access for:

SelfNon-Patient (Parent/Legal Guardian who is not patient of LCMC)

First Name:

Middle Initial:

Last Name:

SSN (xxxxxxxxx):

DOB (xx/xx/xxxx):

Address:

City:

State:

Zip Code:

Phone (xxx-xxx-xxxx):

Email Address:

Primary Physician:

Child Information

Child's First Name:

Child's Middle Initial:

Child's Last Name:

DOB (xx/xx/xxxx):

Relationship to child:

Birth ParentStep-ParentLegal Guardian*Adoptive Parent

Child’s Physician:

*Legal Guardianship papers must be on file before access can be granted

Additional Child Information

Child's First Name:

Child's Middle Initial:

Child's Last Name:

DOB (xx/xx/xxxx):

Relationship to child:

Birth ParentStep-ParentLegal Guardian*Adoptive Parent

Child’s Physician:

*Legal Guardianship papers must be on file before access can be granted

Additional Child Information

Child's First Name:

Child's Middle Initial:

Child's Last Name:

DOB (xx/xx/xxxx):

Relationship to child:

Birth ParentStep-ParentLegal Guardian*Adoptive Parent

Child’s Physician:

*Legal Guardianship papers must be on file before access can be granted

PLEASE READ AND CERTIFY

LCMC Health includes Children's Hospital of New Orleans, Touro Infirmary, New Orleans East Hospital, University Medical Center, and West Jefferson Medical Center.

By clicking the checkbox below, I certify all information provided in this form is true and correct, I am the person submiting this request (and if applicable) I am the birth/adoptive parent or legal guardian of the child and/or children listed above. By signing this form, I acknowledge that I have read and I agree to its terms and conditions. I hereby request access to my own and/or child and/or children’s online health record.

I Certify:

Yes