Name: | DOB: | MRN: | PCP:

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

Note: Adolescent patients aged 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 Medical Center and Connecticut Children’s Specialty Group, Inc. (“Connecticut Children’s”) provides its patients and their families with the ability to access parts of the patient’s medical record through an online application called MyChart.

To obtain an activation code for MyChart, 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.

Link to our Terms and Conditions

Child Information:

Requestor (Parent or Legal Guardian) Information (if patient is under age 18):

Do you wish to add additional children?  

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 (for patient 18+) or my child’s (the patient’s) medical information. I also acknowledge that I have read and understand the general terms and conditions set forth in the link above.

What happens next?

Once we receive your submitted Activation Code Request form, we will send access instructions and a personalized secure activation code to the email address you have provided.