Name: | DOB: | MRN: | PCP:

Request to Access a Minor's Record

Account Access Request

Parents or guardians who have a LCMC Health Patient Portal account, can obtain access to their minor's information through their own Patient Portal account. If you have a Patient Portal account: 1) log in to your account, 2) select the Messaging tab, and 3) click Request Family Access.

Parents or guardians who are not patients of LCMC and need access to their minor's medical record, please 1) select the "Non-Patient" checkbox, 2) complete the entire form (including the Child Information section), and 3) submit the form.

Self or Parent/Legal Guardian Information

Requesting Access for:

Child Information

Relationship to child:

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

Additional Child Information

Relationship to child:

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

Additional Child Information

Relationship to child:

*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: