Age 0-13 Patient: Proxy Access to MyPennMedicine

Requirements and Procedures

Birth/adoptive parents or legal guardians can access myPennMedicine for their children who are under Age 18. Certain myPennMedicine features will be disabled when children turn 14 years of age. Partial access will remain available until children turn 18 years of age. The adolescent may complete the separate Parent or Guardian Access to the myPennMedicine Account of an Adolescent Patient Terms & Conditions form, in person to allow continued full access Proxy to their account.

Requirements for accessing a child’s myPennMedicine account:

Birth/adoptive parent or individual requesting access must have legal guardianship rights.
Parental Authorization Form must be completed and signed.
Each parent or individual requesting access must have their own myPennMedicine account or one will be established for them.

I understand that:

MyPennMedicine is not to be used in an emergency.
I must have a myPennMedicine account or an account will be established for me.
I must log in to myPennMedicine with my own user ID and password.
I must click on my child’s tab to access their medical information.
To receive notifications about new information in my child’s account, I must provide a valid email address.
I agree to abide by the Terms and Conditions of the myPennMedicine site.

I understand that my access to the account of my child will be revoked or limited:

Starting when my child turns 14 years old, unless the adolescent consents to continued access.
In accordance with state or federal law providing minors with access to certain health services and related health information, or
When access disputes between or among parent(s)/legal guardian(s)/child cannot be resolved

Penn Medicine reserves the right to revoke online access to medical information at any time for any reason.

I understand that the following additional procedures apply:

If I have a myPennMedicine account, I will receive a message in that account when access to my child’s account is available. This is typically within 5 to 7 business days after the completed authorization form is received.
If I do not have a myPennMedicine account, I will receive a myPennMedicine activation e-mail with instructions on how to create one. If I do not activate my account within 60 days of receiving my e-mail, my pending account request will be deactivated. Therefore, I should promptly activate my account.
Communications on behalf of my child must be sent from my child’s account and responses will be received in my child’s account. This feature is currently only available to proxies of patients under the age of 14 and those over the age of 14 who have completed the Adolescent Terms and conditions form.
By activating your myPennMedicine account your communication preferences will default to myPennMedicine. Penn Medicine may, from time to time, wish to communicate with you through myPennMedicine about health-related benefits and services that may be of interest to you
Entries I make may become part of the legal medical record of my child.

Patient's Full Name*

First NameLast Name

Patient's Date of Birth*

Format as MM/DD/YYYY

Gender

MaleFemaleOther/NonBinary

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient's Email Address:

example@example.com

Proxy's Name:*

First NameLast Name

Any former names (including maiden names) of the proxy:*

If none, type "none".

Proxy's Contact Phone Number:*

Please enter a valid phone number.

Proxy's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Proxy's Date of Birth*

Format as MM/DD/YYYY

Proxy's Gender

MaleFemaleOther/NonBinary

Proxy's Email Address

To receive notifications about new information in the patient’s account, you must provide a valid email address.

I would also like a myPennMedicine account created for myself, using this email address.

Yes, pleaseNo, thanksNo, thanks, I already have a myPennMedicine account

Proxy's Relationship to the Patient*

ParentLegal GuardianAdoptive ParentOther:

Note: Access to child’s myPennMedicine account is only available to birth parents or individuals with legal guardianship.

Are you (parent/legal guardian) a current or past Penn Medicine patient?*

YesNoDon't Know

Do you (parent/legal guardian) have an active myPennMedicine account?*

YesNoDon't Know

Re-Type the Requestor's Full Name:

First NameLast Name

Use Mouse or Cursor to provide Signature of Requestor: (requesting access)

Press Submit below to finalize this form and submit it to our staff.

Proxy Access to MyPennMedicine Chart

Terms & Conditions: Parental Access to the Account of a Child under Age 18 with partial view at age 14 (ages 0-13)

Please enter the information below for the patient whose myPennMedicine account will be accessed by a proxy:

Please enter the information below for the proxy (person) who will be accessing the above patient's account:

Verification and Signatures