Washington University Physicians

Washington University FollowMyHealth Patient Portal Minor (Child) Request Form

What is a proxy access for a health record?

Proxy access allows a parent, guardian or other legally authorized adult to log into Washington University Follow My Health and connect to the account of a family member or another person.

If you are a proxy for a minor child you will have access to his or her medical record, the ability to message providers and refill prescriptions until the minor reaches the protected age. That age is determined by state and federal law requirements.

If you wish to gain access to your child’s (a minor) medical information, you will need to request a proxy account.

What paperwork do I need to have?

In most instances, you do not need to provide any documentation to us to establish an account for a minor child. However, if there has been a legal or court decision made regarding the custody or guardianship of the child in question, please provide copies of the parenting plan, custody documents or guardianship documents to:

Privacy Office
Washington University
Campus Box 8098
660 S. Euclid, 63110

or fax to 314-362-1199.

How long does it take?

For the protection of our patients, proxy accounts will only be granted to people who have the legal right to request medical information on behalf of our patient. Because this must be verified, proxy accounts may take longer to complete.

How do I sign up?

To request a proxy account, please fill in the boxes below and click Submit. When the documentation has been verified, you will receive a proxy account invitation via the email address you provide below.

Note: Boxes that require an entry are marked with an *.

About You

* First Name:
* Last Name:
* E-mail:
* Confirm E-mail:
* Mailing Address:
* City:
* State:
* ZIP/Postal Code:
* Telephone:  -  -  (###-###-####)
* Enter Invitation Code: This is provided by the clinic or on the portal brochure.

About the Patient (minor child)

* First Name:
Middle Initial:
* Last Name:
* Date of Birth:  /   /  (mm/dd/yyyy)
* Sex:
Soc. Sec. No.:  -  -  (###-##-####)
* Relationship to you:
Patient is unable to consent?
* Legal Documentation:
Select File:
  If you are requesting a proxy account for a minor patient under the age of 18, please enter Yes if you are not the birth parent and have legal documentation (court papers) stating you have responsibility for this person's healthcare. If there is no legal documentation, answer N/A or No. If you answer yes, please send copies of the documentation to the Washington University Privacy Office at Campus Box 8098, 660 S. Euclid Ave., St. Louis, MO, 63110 or fax to 314-362-1199.
* Provider:

This is the full name of the provider/location where the patient was informed about the Washington University Follow My Health patient portal.

 Your infomation will be retained.