Patient Portal Proxy Access Consent Form – Patient Age Birth - 17

myCHP is an online portal that offers free access to your medical information and allows you to conveniently connect with your health care team.

We understand that you wish to access Children’s Hospital’s online patient portal. Regarding this matter, privacy of your/your child’s health care information is important to us. To obtain access, please review and complete the below request form. Expect a two-business day turnaround.

Enrollment for myCHP is available for patients age 13 to 17 years and proxies (parent and/or legal guardian) of patients age birth to 17 years.

Do you already have an account? Login to myCHP to access your medical information.

For questions about myCHP, please contact out 24-hour, customer support line at 1-877-621-8014

All fields are required.







By signing below, I acknowledge that I have read and understand the myCHP Terms and Agreement, and I agree to these terms.




myCHP Terms and Agreement
myCHP Terms and Agreement
  1. I understand that myCHP is intended as a secure online source of confidential patient protected health information. If I share myCHP username and password with another person, that person will be able to view my health information.
  2. I understand that, upon the patient turning age 13, all current proxy access will be limited.
  3. I understand that, upon the patient turning age 18, all current proxy access will be discontinued.
  4. I agree that it is my responsibility to select a confidential password, to maintain that password in a secure manner, and to change that password if I believe or know it may have been compromised in any way.
  5. I understand that myCHP contains select medical information from the patient's medical record and that myCHP does not reflect the complete contents of the medical record. I further understand that myCHP contains information from Children's Hospital physician offices that use the Children's Hospital's electronic health record system, and that I will be able to access information from all of thse physician offices. Such information may be associated with HIV, mental health, and drug and/or alcohol treatment.
  6. I understand that by gaining access, I will be permitted to do the following:
    • request appointments for healthcare services with Children's Hospital health care providers.
    • view the medical information that is available within myCHP
    • communicate with any of my Children's Hospital health care providers, via myCHP, regarding tests, treatments, medication, patient advice, and administrative tasks
    • communicate, via myHCP, with UPMC's billing office regarding any UPMC bills
  7. I understand that all activities within myCHP will be tracked by computer audit and that entries will become a permanent part of the medical record.
  8. I understand that communication could be re-routed and not sent directly to the Provider. The messages will be reviewed and responded to or forwarded appropriately.
  9. I understand that myCHP is not to be used in the event of medical emergencies. In the event of an emergency, I understand that I should either dial 9-1-1 or go to the closest hospital emergency room.
  10. I understand that access to myCHP is provided by Children's Hospital as a convenience to its consumers. myCHP is not a substitute of the full medical record. Children's Hospital has the right to deactivate access to my account at any time for any reason, including cases where Children's Hospital reasonably believes that it is not in the best interest to continue providing myCHP access to me.
  11. Children's Hospital has the right to deactivate access to the myCHP account at any time and for any reason, without explanation, including cases where Children's Hospital reasonably believes that it is not in the best interest to continue providing myCHP access to me
  12. I will not use myCHP access for purposes unrelated to the patient's care or treatment.
  13. I understand that myCHP access is for the care of the patient. If I no longer want to have access, I should contact Children's Hospital by submitting the designated online form available on chp.edu/mychp. Expect a response within two business days.

PROXY INFORMATION












By signing below, I acknowledge that I have read and understand the myCHP terms and Agreement, and I agree to these terms. By signing as proxy, I represent that I am the parent or legal guardian of the child and can consent to release of the information for the patient named in this form.





myCHP Terms and Agreement
myCHP Terms and Agreement
  1. I understand that myCHP is intended as a secure online source of confidential patient protected health information. If I share myCHP username and password with another person, that person will be able to view my health information.
  2. I understand that, upon the patient turning age 13, all current proxy access will be limited.
  3. I understand that, upon the patient turning age 18, all current proxy access will be discontinued.
  4. I agree that it is my responsibility to select a confidential password, to maintain that password in a secure manner, and to change that password if I believe or know it may have been compromised in any way.
  5. I understand that myCHP contains select medical information from the patient's medical record and that myCHP does not reflect the complete contents of the medical record. I further understand that myCHP contains information from Children's Hospital physician offices that use the Children's Hospital's electronic health record system, and that I will be able to access information from all of thse physician offices. Such information may be associated with HIV, mental health, and drug and/or alcohol treatment.
  6. I understand that by gaining access, I will be permitted to do the following:
    • request appointments for healthcare services with Children's Hospital health care providers.
    • view the medical information that is available within myCHP
    • communicate with any of my Children's Hospital health care providers, via myCHP, regarding tests, treatments, medication, patient advice, and administrative tasks
    • communicate, via myHCP, with UPMC's billing office regarding any UPMC bills
  7. I understand that all activities within myCHP will be tracked by computer audit and that entries will become a permanent part of the medical record.
  8. I understand that communication could be re-routed and not sent directly to the Provider. The messages will be reviewed and responded to or forwarded appropriately.
  9. I understand that myCHP is not to be used in the event of medical emergencies. In the event of an emergency, I understand that I should either dial 9-1-1 or go to the closest hospital emergency room.
  10. I understand that access to myCHP is provided by Children's Hospital as a convenience to its consumers. myCHP is not a substitute of the full medical record. Children's Hospital has the right to deactivate access to my account at any time for any reason, including cases where Children's Hospital reasonably believes that it is not in the best interest to continue providing myCHP access to me.
  11. Children's Hospital has the right to deactivate access to the myCHP account at any time and for any reason, without explanation, including cases where Children's Hospital reasonably believes that it is not in the best interest to continue providing myCHP access to me
  12. I will not use myCHP access for purposes unrelated to the patient's care or treatment.
  13. I understand that myCHP access is for the care of the patient. If I no longer want to have access, I should contact Children's Hospital by submitting the designated online form available on chp.edu/mychp. Expect a response within two business days.


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