Name: | DOB: | MRN: | PCP: | Legal Name:

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 create a My Sanford Chart record for you and your child. All fields must be completed to verify your My Sanford Chart membership. Information that is not correct or not complete may delay your request.

To request a paper copy of your child's record, contact your child's primary care clinic or click here for more information.

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

First name

Middle name

Last name

Street address

City

State

Zip

Date of birth

Confirm date of birth

SSN (Last four digits)

Confirm SSN

Daytime phone

Email address

Confirm email address

Child 1

First name

Middle name

Last name

MRN

Date of birth

Confirm date of birth

SSN (Last four digits)

Confirm SSN

Relationship to child

Birth ParentStep-ParentLegal GuardianOther

Specify relationship

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

Child 2

First name

Middle name

Last name

MRN

Date of birth

Confirm date of birth

SSN (Last four digits)

Confirm SSN

Relationship to child

Birth ParentStep-ParentLegal GuardianOther

Specify relationship

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

Child 3

First name

Middle name

Last name

MRN

Date of birth

Confirm date of birth

SSN (Last four digits)

Confirm SSN

Relationship to child

Birth ParentStep-ParentLegal GuardianOther

Specify relationship

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

Child 4

First name

Middle name

Last name

MRN

Date of birth

Confirm date of birth

SSN (Last four digits)

Confirm SSN

Relationship to child

Birth ParentStep-ParentLegal GuardianOther

Specify relationship

*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.

Additional children

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.

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