Portal Access Request | Minor 0-17 Authorized Representative

Parent or Legal Guardian First Name: *

Parent or Legal Guardian Last Name: *

Parent or Legal Guardian Date of Birth: *

Parent or Legal Guardian Sex: *

Male	Female
Both	Unknown

Address Line 1: *

Address Line 2:

City: *

State: *

Zip Code: *

Phone Number: *

Email Address: *

Please Re-Enter Email Address: *

Relationship to Patient: *

MRN	Date of Service
SSN	I do not have

Last four of your SSN	Year you got married
Year you graduated high school	Year your father graduated high school
Year your father was born	Year your mother graduated high school
Year your mother was born	Your postal code

Request for Authorized Representative Seeking Access to Minor’s McLaren HealtheLife Portal