Do not use this form to request access to a family member’s chart. For more information, click HERE.

Improperly obtaining access to another's medical records without a valid patient authorization is against State and Federal confidentiality law and is subject to fines and/or imprisonment.

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We need some information in order to grant you a MyChart account. Enter your demographics here and in the next step we will verify your identity using questions from a third-party verification system. When you're approved, you will receive an email or a letter with your activation code and instructions on how to activate your MyChart account. If you have any questions, please contact your clinic.

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First, we need to collect some information about the patient. If you have any questions, please contact us at (555) 555-5555.

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Now, we need to collect some information about you. After you submit the request, we will set up your appointment. If you have any questions, please contact us at (555) 555-5555.

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We need to collect some information about the patient in order to schedule this appointment. If you have any questions, please contact your clinic.