Welcome to MyChart

What is MyChart?

MyChart offers patients access to their personalized medical and health insurance information over a secure Internet connection.

Who can enroll?

There are several qualifications for participation in the MyChart program:

• Over 18 years of age
• Internet access
• A participating primary care provider

How do I register?

First, please read the MyChart Terms and Conditions statement. Then print out this page and fill out the following information confirming that you have read, understood, and agreed to the items detailed in the Terms and Conditions. You may fax or e-mail this information to us.

MyChart Registration Form

Name: ________________________________________ Date of Birth: ________________________________________ MRN: ________________________________________ E-Mail Address: ________________________________________ Home Phone: ________________________________________ Work Phone: ________________________________________ Mailing Address: ________________________________________ ________________________________________ ________________________________________ Primary Care Provider: ________________________________________

I have read and understood the MyChart Terms and Conditions statement and consent to the terms detailed therein.

Signature: ________________________________________ Date: ________________________________________

Send this form to us at:

Organization Name Attn: Program Name Address 1 Address 2 Fax #

What happens next?

Once we receive your signed consent form, we will send access instructions and a personalized secure activation code to your home address via U.S. mail.

How can I contact your organization?

Please feel free to contact us if you would like the consent form mailed to your home address or if you have any questions about this program. Members of our MyChart support team are available to assist you Monday through Friday from 9:00 a.m. to 5:00 p.m. at (555) 555-5555.

Thank you for your interest!