Name: | DOB: | MRN: | PCP:

Parent/Legal Guardian Access to Minor Patient's Health Information in My UNC Chart

Parents and Legal Guardians may request access to their minor child’s electronic protected health information in My UNC Chart by completing this form if the minor child:

  • • Has not reached his/her 18th birthday;
  • • Is not married;
  • • Is not legally emancipated; and
  • • Is not a member of the Armed Forces of the United States.

Please Note: For Children 13 to 17 years old, the health information you'll be able to view will be limited. When your child turns 18, your access will be turned off completely. Your teen child can choose to give you full access in both of these cases by completing and submitting the proper forms.

The access will change at these ages because of legal requirements. These age limitations do not affect any legal right you may have to access your child's records by other means.

With this form you can request access for up to 3 children. To request access for additional children, please complete another form.

Minor's Information:

Additional Minor:

Additional Minor:

Parent or Legal Guardian Information:

**Legal guardianship papers must be sent to UNCHCS HIM before access can be granted. Submit VIA EMAIL (relmedinfo@unchealth.unc.edu), FAX (919-966-6295) OR MAIL (UNCHCS HIM, Building 500 Eastowne Drive, Chapel Hill, NC, 27514)

Acknowledgement and Authorization:
I acknowledge and agree that:

• I am the custodial parent or Legal Guardian of the minor child identified above and am legally authorized to access the minor child’s electronic protected health information.
• I will be using my My UNC Chart Legal Proxy account to access the minor child’s electronic protected health information.
• I will comply with the My UNC Chart’s Terms and Conditions.
• I recognize that, unless the minor child consents, I am not entitled to access my minor child’s electronic protected health information regarding medical health services for the prevention, diagnosis and treatment of: (1) venereal or other communicable diseases; (2) pregnancy; (3) abuse of controlled substances or alcohol; or (4) emotional disturbance.
• My access to the minor child’s electronic protected health information through My UNC Chart will expire upon the occurrence of any one of the following events: (1) the minor child attains 18 years of age; (2) the minor child marries; (3) the minor child becomes legally emancipated; (4) the minor child becomes a member of the Armed Forces of the United States; (4) my parental rights are terminated or my legal guardianship of the minor child is terminated, revoked or expired; or (5) I revoke this Authorization. In the event that (2)-(5) of the foregoing occur, I will immediately notify UNC Health Care and will cease accessing the minor child's electronic protected health information via My UNC Chart.

Enter your first and last name in the boxes below to serve as your electronic signature.