Parental Access

Personal Health Record Minor Authorization Form

Dear Parent or Guardian,

We are writing to let you know that unless the attached “Personal Health Record Minor Authorization Form” is signed and returned to one of our participating hospitals, electronic access to medical information about your child or children through the RelayHealth Jersey Health Connect Patient Portal (the “Portal”) will be suspended after March 15, 2016. Unless you and the effected minor(s) complete this form and return it, the next time you log in after March 15th, you will be required to terminate access to your minor’s record.

We are implementing this change to the Portal because state law lets your minor child consent to certain health care services without your approval. We call this “Independent Minor Care”. In some Independent Minor Care situations, a minor child also has the right to say that she/he does not want her/his parent to access that information, and your health care provider is required to honor that request. However, our Portal technology is not currently capable of suspending parental access only if and when a minor child receives Independent Minor Care. Therefore, it is necessary for us to suspend all Portal accounts until Dependent Child Authorization Forms are signed and returned to us.

This does not prevent you from getting access to and copies of your medical records or medical records for your child/children directly from your health care provider. If you need a copy of your medical record or the medical record of your child/children, you may still submit your request directly to your treating health care provider.

If you want to continue to have electronic access to your Portal account(s), the attached Minor Authorization Form must be signed by you and your child/children and returned to your Jersey Health Connect/Relay Health participating health care provider prior to March 15, 2016.

If you have a minor which will reach the age of 12, after this date, and you wish to continue access to their PHR, or if you have a minor age 12-17 which obtains services and will be using their PHR, and you wish to have access to that record, you will need to complete and return the form as above.

  • Click here to download the Personal Health Record Minor Authorization Form (Minor PHR Access.pdf)
  • Click here to download this notice
  • Click here to download a contact list for our current member hospitals

Downloads are in PDF format. If you need a PDF viewer, you may download Adobe’s Acrobat Reader from