Sharp Health Plan - Request to Access a Minor's Record

Request access to a child's account

Use this form to request access to a minor's Sharp Health Plan account. Enter your personal information, followed by the minor's information (below age 12) below.

Your information

First Name:

Last Name:

Date of Birth:

Legal Sex:

Phone type:

HomeWorkMobile

Phone:

Street Address:

City:

State:

ZIP:

Email:

Minor information

The person (under age 12) for whom you are requesting account access.

Your relationship to the minor:

If other, please specify:

Member ID:

First Name:

Last Name:

Legal Sex:

Date of Birth:

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