FORM A - Cleveland Clinic

FORM A CLEVELAND CLINIC
MYCHART CAREGIVER REQUEST FORM
(Required for Caregiver Access)
Health Data Services, Ab-7
9500 Euclid Avenue
Cleveland, OH 44195
Revised 5/20/09
Office: (216) 444-2640
Toll-free: (800) 223-2273 ext.U42640U
Fax: (216) 636-0991
UDirectionsU:
Form A: UMyChart Caregiver Request FormU: Must be completed by the person requesting access (requestor) to a patient’s
MyChart account when the requestor does not have a current MRN or CC#. Must be accompanied by either a form B or C.
Form B: UMyChart Caregiver Pediatric Access Request FormU: Must be completed to grant MyChart Caregiver Access to a
pediatric patient’s account.
Form C: UMyChart Caregiver Adult Access Request FormU: Must be completed to grant MyChart Caregiver Access to an
adult patient’s account.
Upon receipt of completed form(s), acknowledgement of account activation will be mailed to requestor via either U.S. Postal
Service or Email.
A MyChart Account must be created to give caretaker’s access to their dependant’s information. The following
information must be provided to generate an activation code for MyChart.
Parent, Legal Guardian or Durable Power of Attorney for
Healthcare:
Requestor’s Name:_________________________________
Requestor’s Telephone #:____________________________
Requestor’s Email:_________________________________
Requestor’s SS#:_________________________________
Requestor’s Date of Birth: _____ / _____ / ______
Requestor’s Current Street Address:
______________________________________________
______________________________________________
City State Zip Code
Are you deaf? Yes_______ No_______ Please select your preferred language:
(If "other" please describe in comment section below.)
English_______ Spanish_______
Other ________________________________
___________________________________________________ __________________
Signature of Patient’s Personal Representative/Parent/Requestor Date
Please submit Form by:
Fax Number: (216) 636-0991
Mail: Cleveland Clinic
Attn: My Chart Caregiver Area
Health Data Services Ab-7
9500 Euclid Ave.
Cleveland OH, 44195
Drop off: Ab 131 (Basement of the A building)

FORM B CLEVELAND CLINIC
MYCHART CAREGIVER ACCESS REQUEST
AUTHORIZATION FORM
Health Data Services, Ab-7
9500 Euclid Ave.
Cleveland, OH 44195
PEDIATRIC
Revised 5/20/09
Office: (216) 444-2640
Toll-free: (800) 223-2273 ext.U42640
Fax: (216) 636-0991
Patient’s Name:___________________________________ Patient’s Date of Birth: _____ / _____ / ______
Patient’s Cleveland Clinic #:_________________________
Patient’s SS#:_________________________________
Patient’s Telephone #:______________________________
Patient’s Current Street Address:
_____________________________________________
_____________________________________________
City State Zip Code
___________________________________________________________________________
Name of facility where UPatientU is seen. (CCF Main Campus, Strongsville Family Health Center, Westside Internal
Medicine etc.)
_________________________________ ________________________________
Requestor’s Name (Print) Requestor’s Clinic Number
_________________________________ ________________________________
Requestor’s E-mail Requestor’s Telephone Number
Please check the authorized party’s relationship to the patient:
□ Custodial Parent
□ Legal Guardian **
□ Non-Custodial Parent
□ Durable Power of Attorney for Healthcare (DPOA) **
**This request MUST be accompanied by a copy of legal paperwork verifying the authority of the patient’s personal
representative (i.e. court appointed guardian, durable power of attorney for health care).
As the patient’s personal representative, I hereby authorize Cleveland Clinic to release health information on the above
patient via MyChart Caregiver according to MyChart Caregiver terms and conditions. I understand and acknowledge that
this may include the patient’s treatment for physical and mental illness, alcohol/drug abuse, and/or HIV/AIDS test results or
diagnoses. I understand that I may discontinue MyChart Caregiver Access at any time by contacting the MyChart
Customer Service Center. For this authorization to be valid, activation of the MyChart Caregiver access feature must occur
within sixty days from the date of this authorization.
__ _____________________________________________ _______________________
Signature of Patient’s Personal Representative/Parent/Requestor Date
Is there a court order or a restraining order in
effect limiting the requesting individual’s
access to this child’s medical records and
information?
__________
Please Write: Yes/No
If yes, please provide legal documents.