Name: | DOB: | MRN: | PCP:

Nationwide Children's MyChart Activation Code Request & Consent

Thank you for your interest in Nationwide Children's MyChart, an easy-to-use tool that provides you quick and secure online access to some of your child's health information.

To sign up for access, please complete and submit the following form for approval. Once your request has been received, we will email you an activation link within 2 business days.

Note: ** indictates required field on the form.

Parent/Legal Guardian Information

**Requesting Access for:

Child Information

**Relationship to child:

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

Additional Child Information

Relationship to child:

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

Additional Child Information

Relationship to child:

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

PLEASE READ AND CERTIFY

I am the parent or legal guardian of the child and/or children listed above and that all information I have provided is correct. By signing this form, I acknowledge that I have read and understand this Nationwide Children's MyChart Consent Form and I agree to its terms and conditions. I hereby request access to my child and/or children's online health record.

I Certify: