Patient Portal - MyChart Access Request - Self or Parent/Legal Guardian

Requesting access for:

Self Non-Patient (Parent/Legal Guardian who is not a patient of LCMC)

Self or Parent/Legal Guardian Information

First Name:

Middle Initial:

Last Name:

SSN:

Enter 9 digits, no dashes (e.g. 123456789).

Date of Birth:

Format: MM/DD/YYYY

Address:

City:

State:

ZIP Code:

Phone:

Format: xxx-xxx-xxxx

Email Address:

Primary Physician:

Complete the section below for each child you are requesting access for (up to three). All child fields are optional - leave a section blank if you do not need it.

Child 1 Information

Child's First Name:

Child's Middle Initial:

Child's Last Name:

Child's Date of Birth:

Format: M/DD/YYYY

Relationship to Child:

Birth Parent Step-Parent Legal Guardian* Adoptive Parent

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

Child's Physician:

Child 2 Information (optional)

Child's First Name:

Child's Middle Initial:

Child's Last Name:

Child's Date of Birth:

Format: M/DD/YYYY

Relationship to Child:

Birth Parent Step-Parent Legal Guardian* Adoptive Parent

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

Child's Physician:

Child 3 Information (optional)

Child's First Name:

Child's Middle Initial:

Child's Last Name:

Child's Date of Birth:

Format: M/DD/YYYY

Relationship to Child:

Birth Parent Step-Parent Legal Guardian* Adoptive Parent

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

Child's Physician:

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