MyChart Sign-up on Behalf of an Adult Patient

This form is to request access to an adult family member's health record in MyChart. This requires an activated Healthcare Power of Attorney or Legal Guardianship Documentation to be filed at SSM Health.

Alternatively, if your family member already uses MyChart, they can grant (and revoke) access to their personal chart within MyChart to any other adult they choose. This is available under Health < Share My Record on the MyChart website.
To access a minors record, a please request for a child proxy account instead.
To create a MyChart account to access your own chart, use our self-signup form.

Proxy or Legal Guardian Information:

First Name *

Last Name *

Last Four Digits of SSN

Date of Birth*

Gender*

Male Female

Street Address*

City*

State*

Zip*

Home Phone Number*

Email Address*

Relationship to Patient*

Patient Information:

First Name *

Last Name *

Last Four Digits of SSN*

Date of Birth*

Insurance Provider*

Primary Care Physician*

Address (If different from legal guardian)

I am requesting this access with the permission of the patient listed. I understand my access can be terminated by the patient at any time for any reason.* I certify that I am either the legal guardian of the patient listed here or am otherwise legally authorized to access this patient's MyChart.