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Screen readers: use read next line command to hear instructions."), "Global"); </script> </head> <body onload="insideBodyLoad(1140000, 1200000, true, ''); assignInlineEventHandlers(); WP.DOM.Browser.checkBrowserSupported();" class="hasNoCommunityLinks isPrelogin publicform color1 graphicHeader md_showForm"> <div id="classicPopupRoot" class="overlayContainer"><div id="onboarding-content" class="jqHidden"></div></div><div id="wrap" class="withSidebar" data-hide-during-popup="true"><div id='vbPrintHeader' class='printheader'></div><header id="header" dir="ltr" lang="en" class="header_graphic"><div class="header_color"></div><div class="fitme width height"><div id="graphicHeader"></div></div></header><div id="content" class="fitme width hasSidebar"><main id="main"><a class="logo" href="/MyChart/" title="MyScripps"></a><div class="title"><h1 class="header">Request Access to a Minor's Record</h1><div id="assistiveicons"><img class="assistiveicon" alt="" src="/MyChart/en-US/images/space.gif" /></div></div> <p><b>Online proxy request is available for access to a minor's account. </b>If you'd like access to another adult's MyScripps, they must log into their own account and send you a Proxy Invite. <br/><br/> We will notify you within 3 business days once proxy access has been set up, or reach out for further follow up if needed. <br/><br/> You will receive full access to the charts of children under the age of 12. Under federal and California law, when minors reach age 12, they have a legal right to health information privacy. In compliance with these laws, we limit the information proxies can view in their teenager's chart. While your child is between the ages of 12-17, you will be able to message their providers, review and refill medications*, schedule appointments, and track growth charts. At this time, proxy access to teens does not allow the viewing of test results, upcoming or past appointments, or letters. <br/> <i>*"Sensitive" medications are filtered from proxy view </i> <br/><br/> If your child has diminished capacity and you need full access to their chart, please notate that below. With specific diagnoses or physician approval, full access will be granted until they turn 18. </p> <form autocomplete="off" method="post" action="/MyChart/publicforms.asp?mode=saveform&formname=OnlineProxyRequestNoLogin" id="OnlineProxyRequestNoLogin"><div class="formcontents"><div class="hidden"><input type="hidden" class="hidden" name="sec_token" value="19EAF819A0B9471F88B4483D780D08C8" /></div> <div class="section"><div class="content"><div class="hidden"><input type="hidden" class="hidden" name="customformtoken" value="81B3C79C4EEA4A58A0ECEB929C805AE6" /></div> <div class="grid compact"><div class="row"> <div class="col-12"> <h2>Minor's Information:</h2></div></div><div class="row"><div class="col-4"><label for="firstName" class="required">First Name:</label></div><div class="col-8"><input type="text" name="firstName" id="firstName" maxlength="60" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="middleName" >Middle Name:</label></div><div class="col-8"><input type="text" name="middleName" id="middleName" maxlength="60" value="" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="lastName" class="required">Last Name:</label></div><div class="col-8"><input type="text" name="lastName" id="lastName" maxlength="60" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="StreetAddress" class="required">Street Address:</label></div><div class="col-8"><input type="text" name="StreetAddress" id="StreetAddress" maxlength="255" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="City" class="required">City:</label></div><div class="col-8"><input type="text" name="City" id="City" maxlength="255" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="State" class="required">State:</label></div><div class="col-8"><input type="text" name="State" id="State" maxlength="60" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="Zip" class="required">Zip:</label></div><div class="col-8"><input type="text" name="Zip" id="Zip" maxlength="60" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="sex" class="required">Sex:</label></div><div class="col-8"><select name="sex" id="sex" size="1" aria-required="true" ><option value="" selected="selected"></option><option value="Female">Female</option><option value="Male">Male</option></select></div></div><div class="row"><div class="col-4"><label for="dob" class="required">DOB:</label></div><div class="col-8"><input type="text" id="dob" name="dob" maxlength="10" value="" class="date withCalendar" onblur="formatDateField(this,0,null,null);" onkeypress="return event.keyCode!=13;" aria-required="true" data-filter="any" /></div></div><div class="row"><div class="col-4"><label for="ssn" class="required">Last 4 SSN:</label></div><div class="col-8"><input type="text" name="ssn" id="ssn" maxlength="4" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="diminishedCapacity" class="required">Is this a diminished capacity minor?</label></div><div class="col-8"><select name="diminishedCapacity" id="diminishedCapacity" size="1" aria-required="true" ><option value="" selected="selected"></option><option value="No">No</option><option value="Yes">Yes</option></select></div></div><div class="row"> <div class="col-12"> <h2>Parent/Guardian Information:</h2></div></div><div class="row"><div class="col-4"><label for="parentFirstName" class="required">First Name:</label></div><div class="col-8"><input type="text" name="parentFirstName" id="parentFirstName" maxlength="60" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="parentMiddleName" >Middle Name:</label></div><div class="col-8"><input type="text" name="parentMiddleName" id="parentMiddleName" maxlength="60" value="" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="parentLastName" class="required">Last Name:</label></div><div class="col-8"><input type="text" name="parentLastName" id="parentLastName" maxlength="60" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="parentStreetAddress" class="required">Street Address:</label></div><div class="col-8"><input type="text" name="parentStreetAddress" id="parentStreetAddress" maxlength="255" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="parentCity" class="required">City:</label></div><div class="col-8"><input type="text" name="parentCity" id="parentCity" maxlength="255" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="parentState" class="required">State:</label></div><div class="col-8"><input type="text" name="parentState" id="parentState" maxlength="60" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="parentZip" class="required">Zip:</label></div><div class="col-8"><input type="text" name="parentZip" id="parentZip" maxlength="60" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="parentDob" class="required">DOB:</label></div><div class="col-8"><input type="text" id="parentDob" name="parentDob" maxlength="10" value="" class="date withCalendar" onblur="formatDateField(this,0,null,null);" onkeypress="return event.keyCode!=13;" aria-required="true" data-filter="any" /></div></div><div class="row"><div class="col-4"><label for="parentSsn" class="required">Last 4 SSN:</label></div><div class="col-8"><input type="text" name="parentSsn" id="parentSsn" maxlength="4" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="parentPhone" class="required">Phone Number:</label></div><div class="col-8"><input type="text" name="parentPhone" id="parentPhone" maxlength="20" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="parentEmail" class="required">Email Address:</label></div><div class="col-8"><input type="text" name="parentEmail" id="parentEmail" maxlength="255" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="relationship" class="required">I am this child's:</label></div><div class="col-8"><select name="relationship" id="relationship" size="1" aria-required="true" ><option value="" selected="selected"></option><option value="Parent">Parent</option><option value="Legal Guardian">Legal Guardian</option><option value="Other">Other</option></select></div></div><div class="row"><div class="col-4"><label for="other" class="required">If other, please specify:</label></div><div class="col-8"><input type="text" name="other" id="other" maxlength="60" value="" aria-required="true" onkeypress="return event.keyCode!=13;" /></div></div><div class="row"><div class="col-4"><label for="parentMyscrippsAccess" class="required">Do you have your own MyScripps account?</label></div><div class="col-8"><select name="parentMyscrippsAccess" id="parentMyscrippsAccess" size="1" aria-required="true" ><option value="" selected="selected"></option><option value="MyScripps Active">Yes, I have my own MyScripps login</option><option value="Not MyScripps Active">No, I don't have a MyScripps login</option></select></div></div><fieldset class="question grid custom " aria-required="true" data-lql="mustCheck" ><div class="row"><div class="col-4"><legend class="form" data-lql="mustCheck" ></legend></div><div class="col-8 required"><p class="button buttoncheck"><input id="mustChecktrue" type="checkbox" name="mustCheck" value="true" class="buttoncheck" onclick="$$WP.Questionnaires.QuestionConditions.checkQuestionConditionsOnclick('mustCheck_true',0,0,'');" aria-required="true" /><label class="buttoncheck" for="mustChecktrue">I certify that I have the legal right to this minor's medical information.</label></p></div></div></fieldset></div><div class="recaptcha formsection"><div id="CAPTCHA"></div><div class="hidden" id="__CAPTCHAkey" data-captcha-key="6LcnP58pAAAAALyHCQjzsTgwRM4Gp1Gx4ZMQZmoB"></div><div class="hidden" id="__CAPTCHAVisibility" data-captcha-visibility="invisible"></div><script src=https://www.google.com/recaptcha/enterprise.js?onload=$$WP$Captcha$RenderAllCaptcha&render=explicit&hl=en-US async defer></script><script src="/MyChart/scripts/models/captcha/googlerecaptchaenterprise.js" type="text/javascript"></script><script type="text/javascript">$$WP.Utilities.UI.OnUIFrameworkLoaded(function () { var $captchaEl = $afe.select("#CAPTCHA"); var $formEl = $captchaEl.closest("form"); var captcha = new $$WP.Captcha($captchaEl); captcha.Render(); captcha.AttachToFormSubmit($formEl); });</script></div></div><input class="button autowidth completeworkflow" type="submit" name="formSubmit" value="Submit Request" data-disable-if-invalid /> <input class="hidden" type="hidden" name="mychartFormName" value="OnlineProxyRequestNoLogin" /> </div> <script type="text/javascript"> function $enableRequiredTextField($field) { $field.val(""); $field.prop({"readonly": false,"tabIndex":0}); $field.removeAttr('style'); } function $disableRequiredTextField($field) { $field.val("N/A"); $field.prop({"readonly": true,"tabIndex":-1}); $field.css({"background-color": "#DDDDDD"}); $field.removeClass("alertborder"); } $afe.onDocumentReady(function () { var $rel = $afe.select( "#relationship" ); var $other = $afe.select( "#other" ); var $check = $afe.select( "input[name=mustCheck]" ); var $checkLabel = $afe.select( "#mustCheck_true" ); var $submit = $afe.select( "input[name=formSubmit]" ); // Disable submit button until checkbox is checked if (!$.isEmptyObject($submit) && !$.isEmptyObject($check) && !$.isEmptyObject($checkLabel)) { if ($check.prop("checked") !== true) { disableBtn($submit[0]); } $check.on("change keyup",function() { if ($afe.jq(this).prop("checked") === true) { enableBtn($submit[0]); } else { disableBtn($submit[0]); } }); $checkLabel.click(function() { if ($check.prop("checked") === true) { enableBtn($submit[0]); } else { disableBtn($submit[0]); } }); } // Disable other text field if Other is not selected if (!$.isEmptyObject($rel) && !$.isEmptyObject($other)) { if ($rel.val() !== "Other") { $disableRequiredTextField($other); } $rel.on("change keyup",function() { if ($afe.jq( this ).val() === "Other") { $enableRequiredTextField($other); } else { $disableRequiredTextField($other); } }); } }); </script> </div></form><div class="back"><a id="backButton" class="button previousstep" title="Back" onclick="$$WP.Utilities.TryRedirect(this.href,null,'1'); return false;" href="/MyChart/default.asp">Back to the Login page</a></div></main><aside id="sidebar"><div id="locale_container" class="prelogin"><a href="/MyChart/publicforms.asp?mode=showForm&formname=OnlineProxyRequestNoLogin&lang=espanol" onclick="$$WP.Utilities.TryRedirect(this.href); return false;"><span class="localename">Ver en Espa帽ol</span><abbr class="abbreviatedname" title="Ver en Espa帽ol">Esp</abbr></a></div></aside><footer id="footer"><div id="mainFooter" class="mainStyle"></div><div id="sidebarFooter" class="sidebarStyle"><div id="mychart_by_epic_logo_wrapper"><img id="mychart_by_epic_logo" src="/MyChart/en-US/images/MyChartByEpic_inline_dark.svg" alt="" /></div><span class="copyright" lang="en"><a href="/MyChart/Authentication/Login?mode=stdfile&option=epiccopyright" onclick="$$WP.Utilities.TryRedirect(this.href); return false;"><span class="copystring">MyChart® licensed from Epic Systems Corporation</span><span class="copyyear"> © 1999 - 2024</span></a></span></div></footer></div><div class="lb_overlay noprint" id="lightbox_overlay" onclick="hideLightbox();"></div> <div class="lb_content" id="lightbox"></div><div id="menuWrapper"></div></div></body></html>