Minor Patient Portal Access Form

Proxy Access for Minor Patients, Ages 0-17
*Parent/guardian access to portal automatically terminates at age 18 and the adult patient will need to re-enroll*

You may request patient portal access or proxy access if you are:

The parent or legal guardian of a minor child under the age of 18
A legally appointed guardian or healthcare decision maker for a patient over the age of 18
Teens ages 13-17 may have access in addition to parents or guardians

Patient Information

Information for the patient to which proxy access is requested.

Patient Name*

First Name

Last Name

Patient Date of Birth*

Please format xx/xx/xxxx

Teen Email Address

If teen wants access to portal

Child’s photo for his/her chart

No File Chosen

File uploads may not work on some mobile devices.

Please upload a current photo of your child.

Does the caregiver bringing the patient to appointments have any special needs or accommodations?*

ie. foreign language interpreter services, behavioral special needs, blind, deaf, etc.

Does the patient have any special needs or accomodations?*

ie. foreign language interpreter services, behavioral special needs, blind, deaf, etc.

New Patient to Le Bonheur Children's?*

Yes No

Patient Social Security Number*

please format xxx-xxx-xxxx

Patient Gender*

Male Female

Patient's Pediatrician*

Parent/Guardian Information for Proxy Access

Parent/Guardian Name*

First Name

Last Name

Parent Birthdate*

Please format xx/xx/xxxx

Relationship to Patient*

4 digit PIN for Challenge Question*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Primary Phone to Call*

Primary Phone to Text

Parent/Guardian Email*

Confirm Parent/Guardian Email *

Parent/Guardian Photo ID Card*

No File Chosen

File uploads may not work on some mobile devices.

Drivers License or legal ID must be validated and a copy provided with this application. A copy of the appropriate legal documentation may also be required.

Insurance Information

Is Insured same as Parent/Guardian above?*

Yes No

Insured Name*

First Name

Last Name

Insured Date of Birth*

please format xx/xx/xxxx

Insured Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Do you have an insurance card? *

Yes No

Insurance Card - Front*

No File Chosen

File uploads may not work on some mobile devices.

Please upload a photo of the front of your insurance card.

Insurance Card - Back*

No File Chosen

File uploads may not work on some mobile devices.

Please upload a photo of the back of your insurance card.

Authorization to Release Protected Health Information

I understand that as the patient’s parent/ legal guardian, by signing this document, I am providing Le Bonheur Children’s Hospital with documentation of my authorization to provide access to this patient’s protected health information through the patient portal.
My rights to access to this patient’s protected health information have not been modified in any manner by any court of law.
The documents I have provided in support of my right to access the patient’s protected health information, if any, are true and correct copies and are the most recent documents related to this matter.
I understand that Le Bonheur Children’s Hospital/Methodist Le Bonheur Healthcare reserves the sole right to determine whether proxy eligibility exists and to whom it will grant Proxy Access rights.
You may receive emails from Methodist Le Bonheur Healthcare.

I agree