MyChart - Sign Up

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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Follow these steps to sign up for a MyChart account.

Enter your personal information.

Verify your identity.

Choose a username and password.

If you have any questions, please contact us at (555) 555-5555.

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Follow these steps to sign up for a MyChart account.

Enter your personal information.

Verify your identity.

Choose a username and password.

If you have any questions, please contact us at (555) 555-5555.

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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.

First name

Middle name

Last name

Date of birth

Legal Sex

Female Male Unknown

Home phone

Mobile phone

Email address

Verify email address

Last four digits of SSN

The last four digits of your SSN will not be stored. We use this to eliminate duplication, expedite service, and prevent identity theft.

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Name

Address

Other Information