Parent Consent Form

Language: English / Spanish

I have been informed that Bellin Health offers its patients a free, secure, online site and app that helps patients manage their own healthcare. This online site and app is called MyBellinHealth. I understand that adolescent patients who are ready to take a more active role in their own healthcare are permitted to establish their own MyBellinHealth accounts. 

I recently spoke with my adolescent child's provider's office. Based on this discussion, I have determined that my adolescent child is ready to have his/her own MyBellinHealth account.

I understand that my adolescent child will be able to perform the following functions through his/her own MyBellinHealth account:

  • Use the online messaging system to chat with his/her provider in a confidential manner
  • Schedule appointments
  • Refill prescriptions 
  • View lab results
  • View and track health results
  • Have a video visit

I also understand that I may be offered proxy access to my adolescent child's MyBellinHealth account. Through my proxy access, I will have limited access to my adolescent child's health information, subject to state and federal laws. I will be able to see their demographic updates and flowsheet entry and use the online messaging system.

I understand that even if I do not have proxy access to my adolescent child's MyBellinHealth account, I can always request copies of my adolescent child's medical records at any time.

I understand that once I submit this form, my adolescent child will receive an email message at the email address listed below with detailed instructions on how to activate his/her own MyBellinHealth account.

I have read, understood, and agree to the terms above.

By submitting this form, I hereby consent to allow my adolescent child to establish his/her own MyBellinHealth account.

Parent's name: *
My adolescent (13-17 year old) child's name: *
My adolescent child's d/o/b: *
My adolescent child's email address: (cannot be parent’s email) *
Your Bellin Health clinic location or specialty: *