MyChart - Signup

MyChart Home » Request Access » Access for Myself

Online Access Request Form

All fields with a * are required

You can gain instant access to your UR Medicine MyChart by filling out all the information below. If your identity is confirmed within our system, you can complete the final account setup steps and begin enjoying the benefits of UR Medicine MyChart. The more information that you provide increases our ability to confirm your identity; however, if you don't know/wish to answer, enter NA.

Important: You must be 18 years and older to request access for MyChart online. If you are under 18, please speak with your doctor's office. If you are a parent, please read these instructions on how to request access to your child’s MyChart.

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. Once verified, 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.

Indicates a required field

Name

First name

Middle name

Last name

Preferred

Address

Address information is required.

AddressCityStateZIPCountyCountry

Address	City	State	ZIP	County	Country
__Street__	__City__	__State.Title__	__Zip__	__County.Title__	__Country.Title__

Other Information

Date of birth

MM/DD/YYYY

Gender Male Female

Home phone

NNN-NNN-NNNN

Work phone

NNN-NNN-NNNN

Last four digits of SSN

NNNN

Medical record number

Email address

Verify email address

Finally, to ensure a person (vs. a machine/robot) is completing this form, start by clicking the box below.

This field is machine-generated content. Please ignore.

Request an Activation Code

Online Access Request Form

Request Submitted

Request Submitted

Request Submitted

Oops! Something is not right here...

Oops! Something is not right here...

Oops! Something is not right here...