Name: | DOB: | MRN: | PCP:

Children's Connect Activation Code Request & Consent

Thank you for your interest in Children's Connect, 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 Children's Connect 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 the following limitations for Children's Connect 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 your child's provider's office directly.

If your child is age 0-18, you will be granted full access to your child's Children's Connect record.

Once your child reaches age 14, he/she will be able to access his/her own Children's Connect record pending approval between the parent/guardian and the provider

Once your child reaches age 19, you will no longer have access to your child's Children's Connect record.

Parent/Legal Guardian Information

Requesting Access for:

Child Information

Relationship to child:

*Legal Guardianship papers must be on file before access can be granted

Additional Child Information

Relationship to child:

*Legal Guardianship papers must be on file before access can be granted

Additional Child Information

Relationship to child:

*Legal Guardianship papers must be on file before access can be granted

PLEASE READ AND CERTIFY

I am the birth/adoptive parent or legal guardian of the child and/or children listed above and that all information I have provided is correct. By signing this form, I acknowledge that I have read and understand this Children’s Connect Consent Form and I agree to its terms and conditions. I hereby request access to my child and/or children’s online health record.

I Certify: