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Parental Authorization Form of a Patient 14 to 17 Years Old

After completing this form, hit the 'Continue' button. Then click the 'Click Here to Print Form' button. Sign the forms and then mail, email, or fax the documentation. If you don't have access to a printer call 570-271-7292 to have the forms mailed to you.

Submission Requirements and Procedures
Asterisk (*) denotes a required field

Part I: Parental Authorization Form

Child Information

Child Address

Requestor (Birth/Adoptive Parent or Legal Guardian) Information

Note: Access to a child´s online record is only available to birth/adoptive parents or legal guardians. If you are not an existing patient, a medical record number will be created for you. To minimize duplicate records, please provide any former names you may have used previously.
Please indicate your relationship to the child by selecting one of the following:*
Birth/Adoptive Parent Legal Guardian

(Please attach proof of legal guardianship to avoid processing delays)

Important Notice for Adoptive Parents: If the child is adopted, please contact Health Information Management at phone number 570-271-6116 to verify that clinical information for your child is made available to the treatment team.

Requestor Address Same as Child?
Do you (parent/legal guardian) have an active MyChart account? Yes No Unsure
Is this request to access the patient's MyChart Bedside information while the child is admitted to the hospital?* Yes No

Part II: Child Access to Account

As the birth/adoptive parent or legal guardian of the child, I am requesting that my child have access to their online medical record:* Yes No