Patient Portal - Proxy Access Request

If you would like to request proxy access to your child's (0-15 years) Patient Portal account, please complete all steps below. For patients aged 16 years and older, proxy access must be requested in person at the relevant Health Service or by completing a printed copy of the sign-up form: My RCH Portal Parent/Legal Guardian Sign-up Form or Health Hub Sign-up Form.

Step 1 | Patient Details:

Parent/legal guardian, please fill in your child's details

Health Service:

Please select the primary Health Service the patient attends. This information will be used to send the request to the correct location for processing.

First name:

Last name:

Date of Birth:

Patient UR number (if known):

Street address:

Suburb/Town:

State:

Post Code:

Phone:

Step 2 | Proxy Details:

Parent/legal guardian, please fill in your details

First name:

Last name:

Date of Birth:

Relationship to patient:

Your UR Number (if known):

If you're a patient at The Royal Melbourne Hospital, The Women's or Peter MacCallum Cancer Centre, we can link your patient record to your Patient Portal account, allowing access to your child's patient record and your own record from the same account.

Street address:

Suburb/Town:

State:

Postcode:

Phone:

Email:

Step 3 | Identity Verification:

To ensure your child's information is protected and secure, a copy of your photo identification (which displays your full name and date of birth) is required to verify your identity. Proof of identification must be provided by email by choosing the relevant Health Service link below. The photo ID will be used solely to verify identity and will not be permanently stored.

The Royal Children's Hospital

The Royal Melbourne Hospital

The Royal Women's Hospital

Peter MacCallum Cancer Centre

Were you able to successfully send proof of identification as described above?

Yes

ID Reference number:

Please supply the reference number found on your ID - e.g. Driver's licence, passport, proof of age card etc.

Important: Your patient portal account request will not be reviewed or approved until a valid form of photo identification has been recieved (e.g. driver's licence, passport, proof of age card, etc.).

Step 4 | Please read and sign this form:

You must read, understand, and agree to the Terms and Conditions of Use posted on the My RCH Portal and Health Hub websites, before an account can be provided. Once you have read this document, please sign the form below:

If you are a parent or legal guardian requesting proxy access to your child's Patient Portal account, click the statement to the right to sign this form electronically - it will turn blue when clicked.

By signing this form electronically, I certify that I am the parent or legal guardian of the patient identified above, and the information I have provided is correct. I acknowledge that I have read, understood and agree to abide by the My RCH Portal/Health Hub Terms and Conditions of Use linked to this form.

Based on the information you provided, we will post, email or text you the details to sign up for the Patient Portal. Please allow seven business days for these requests to be processed. Should we have any questions regarding your submission, we will contact you via the telephone number or email you have submitted.

Proxy Access Request for Child 0-15 years

Step 1 | Patient Details:

Step 2 | Proxy Details:

Step 3 | Identity Verification:

Step 4 | Please read and sign this form: