Request to Access a Minor's Account for ages 11 and under.

Enter information about the minor to whom you are requesting access. All fields are required.

Parent/Guardian:

First Name:

Last Name:

Your DOB:

Your Social Security Number:

Phone:

Address:

City:

State:

Zip Code:

E-mail Address:

Minor:

First Name:

Last Name:

Sex:

DOB(ages 11 and under only):

Social Security Number:

Additional information:

This minor is your:

If other, please specify:

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

Mark as confidential (only you will be able to view this message online).

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