First Name Last Four Digits of SSN Street Address State Home Phone Number Last Name Date of Birth City Zip Code E-mail Address Gender MaleFemale Relationship to Patient SpouseSon/DaughterSiblingOther RelativeLegal GuardianDesignated Decision Maker Patient Information: First Name Last Four Digits of SSN Insurance Provider Primary Care Physician Address (if different from legal guardian) Last Name Date of Birth I am requesting this access with the permission of the patient listed. I understand my access can be terminated by the patient at any time for any reason.* I certify that I am either the legal guardian of the patient listed here or am otherwise legally authorized to access this patient's MyChart.
