Name: | DOB: | MRN: | PCP:

Proxy Access Request

Thank you for your interest in mySRH, an easy-to-use internet tool that provides you quick and secure online access to some of your child's health information. To sign up for access to your child's mySRH record, please complete and submit the following form for approval. Once your request has been approved, we will email your activation code within 7 business days. We will contact you if we have any questions regarding your information. Please note that access to a child’s record through mySRH can only be granted to a Parent or Legal Guardian.

Please note the limitations below for mySRH based on your child's age. These age range limitations do not affect any legal right you have to access your child's records by other means. To request a paper copy of your child's record, contact the HIM Department at 214-559-7455.

If your child is age 0-17 years, you will be granted full access to your child's record.

Once your child reaches age 14 years, he/she will be able to access his/her own mySRH record pending the approval of the parent/guardian.

Once your child reaches age 18 years, you will no longer have access to your child's mySRH record.

If you are a patient over the age of 18 requesting access to your own record, please complete the Self Acess Request: Self Access Request

Parent/Guardian/Legally Responsible Person Information 

Date of birth of the parent or legal guardian.

Requesting access for:
Child's Information 
Relationship to Child*
Are you the legal guardian for this patient?
 
Additional Child's Information 
Relationship to Child*
Are you the legal guardian for this patient?
 
Additional Child's Information 
Relationship to Child*
Are you the legal guardian for this patient?
 
Certification

I certify that I am the patient or legally authorized representative of the patient. By signing this form, I acknowledge that I have read and understand this mySRH Request Form and I agree to its terms and conditions. I hereby request access to my child and/or children’s online health record.

Certification*
If you have any questions, please contact the Health Information Management office at 214-559-7455.