Request to Access MyChart

Thank you for your interest in Driscoll Health System MyChart. This easy-to-use tool can be accessed anywhere and gives you quick and secure access to your child’s information. To sign up for access to Driscoll Health System, please fill out and submit the form below for approval.

Once your request is approved, we will email or text you an activation code within two business days. We will reach out to you if we have any questions about your information. Access to a child's information through Driscoll Health System can only be granted to a parent or legally authorized representative. Your ability to access your child's information will vary based on the child's age. Please see below for details.

Parent/Legal Guardian/Adult Patient Information:

First Name:

Middle Initial:

Last Name:

SSN:

DOB(xx/xx/xxxx):

Address:

City:

State:

Zip Code:

Mobile Phone(xxx-xxx-xxxx):

Email Address:

Primary Care Provider:

Requesting Access for:

Existing AccountNew AccountSelf

Child information:

Child's First Name:

Child's Middle Initial:

Child's Last Name:

SSN:

DOB(xx/xx/xxxx):

Relationship to child:

Birth ParentStep-ParentLegal GuardianAdoptive Parent

Additional Child information:

Child's First Name:

Child's Middle Initial:

Child's Last Name:

SSN:

DOB(xx/xx/xxxx):

Relationship to child:

Birth ParentStep-ParentLegal GuardianAdoptive Parent

Additional Child information:

Child's First Name:

Child's Middle Initial:

Child's Last Name:

SSN:

DOB(xx/xx/xxxx):

Relationship to child:

Birth ParentStep-ParentLegal GuardianAdoptive Parent

Driscoll Health Plan Member:

If you are a Driscoll health plan member please enter your member ID below. If you request access to more than one child, separate the member's IDs with a comma.

Member ID:

I certify that I have the legal right to this minor's medical information.

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