Name: | DOB: | MRN: | PCP:

MyChart Access for Parent, Guardian, or Adult Patient (Age 18+)

Patients age 13-17 can access MyChart but will need their own account.
Teen accounts can only be created in person - talk with your health care provider or the front desk staff at your next visit.



Connecticut Children’s and Connecticut Children’s Specialty Group, Inc. (“Connecticut Children’s”) provides our patients and their families access to parts of the patient’s medical record through an online application called MyChart.

In order to create a MyChart account, please complete the form below. All fields are required to verify your eligibility. You or your child must be a patient of Connecticut Children's primary or specialty care.

If you already have an unexpired 15-digit activation code, please visit this page to create your account.

Child Information:

Requestor (Parent or Legal Guardian) Information:

 

If you have additional children who are also patients of Connecticut Children's, please enter their information below. Otherwise scroll down to submit this form.

Additional Child Information:

 

Additional Child Information:

 

I understand that by submitting this form I am authorizing Connecticut Children’s to create an account for me to access a limited portion of my or my child’s (the patient’s) medical information. By clicking 'Submit Request' I certify that I have the legal right to this patient's medical information.