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 to your child's Nationwide Children's MyChart record, please complete and submit the following form for approval. Once your request has been received, we will email you an activation code within 7 - 10 business days.

Please note there could be a delay with processing your request due to, but not limited to the following reasons:

1. If your child is 13 years or older, Ohio Law requires Nationwide Children's Hospital to obtain the patients consent in order to provide the legal guardian access to their MyChart record.

2. If your child is 18 years or older, you will no longer have access to your child's Nationwide Children's MyChart record.

3. If we are unable to verify the requesters identity based on the information provided below.

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:
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