Name: | DOB: | MRN: | PCP:

Activation Code Request


Welcome! We are pleased to offer this on line request service for your MyChart activation code. Your activation code will be your key to your personal and secure electronic medical record. Please fill out all fields, as they are required to verify your membership.

Your activation code will be emailed to the email on file once all information has been verified. If you are not able to validate your current email address your activation code will be mailed to the address on file. Should we have any questions regarding your submission, we will contact you via the home phone number on file.