MyChart -

All fields with a * are required.

If you tried to login five times or more to MyChart and were unsuccessful, we have locked your account for security reasons. Please fill out the form below to help us verify your identity prior to re-activating your account (this may take up to two business days). Look for an email from UR Medicine MyChart Customer Service, which will contain the next steps on how to re-activate your account. You can also provide additional comments in the space provided below.

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First Name*	Address*
Last Name*	City*
Date of Birth (MM/DD/YYYY)*	State*:
Daytime Phone*	Zip Code*
UR Medicine Physician (recently seen)*	Email Address*
Medical Record Number (If known)	Additional Comments (optional)

Non-Verbal Username/Password Help