Name: | DOB: | MRN: | PCP:

Child Proxy Access Request

Welcome! Sanford Health is pleased to offer this online request service for access to your child's My Sanford Chart record. Please note that your child's chart will be accessed through your My Sanford Chart record. Completing this request will establish a My Sanford Chart record for you and your child. Please fill in all fields, as they are required to verify your My Sanford Chart membership.

Please note the following age range limitations for My Sanford Chart. These age range limitations do not affect any legal right you have to access your child's record by other means. To request a paper copy of your child's record, contact your child's primary care clinic or click here for more information.

  • If your child was born after April 7, 2003: You will be granted full access to your child's My Sanford Chart account.
  • If your child was born on/or before April 7, 2003: Your teenager will need to complete the My Sanford Chart Adult/Teen Proxy Form before full access will be granted.
  • Once your child reaches age 18, you will no longer have access to your child's My Sanford Chart record.

* Required Field

Parent/Guardian Information
Child 1
Relationship to child

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

Child 2
Relationship to child

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

Child 3
Relationship to child

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

Child 4
Relationship to child

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

Additional Children

If you have more than 4 children for whom you would like proxy access, please provide each of the additional children's information in the box below.

Enter the text as you see it below.This proves you're a real person and not an automated program attempting to log in to your account.

After validating your submission with your My Sanford Chart membership information your activation code will be emailed to you. Your activation code will allow you to create your My Sanford Chart account. Please allow up to one business day for processing and verification. Should we have any questions regarding your submission, we will contact you via the daytime phone number you have submitted.