Please Identify Yourself

Step 1 of 3: By completing the enrollment form below, you authorize The Christ Hospital Health Network to release your protected health information to you via MyChart. This authorization is effective until your MyChart account is inactivated and includes records that were created or existing on or before the date you signed up for MyChart, as well as records that are created after today. You also understand that the information to be released may include information relating to the diagnosis and/or treatment of mental illness, alcohol/drug abuse, STD's, HIV test results, developmental disabilities, and genetic testing results. You have the right to revoke this authorization at any time by contacting your physician's office. This revocation will not apply to information that has already been released.

All fields are required.

MyChart Activation Code

Enter your Activation Code as it appears on your enrollment letter (your code is not case sensitive). You will not need to use this code after you complete the signup process.

xxxxx
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xxxxx
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xxxxx

Please enter the last 4 digits of your Social Security Number.

nnnn
Date of Birth

Enter your date of birth in the format shown, using 4 digits for the year.

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dd
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yyyy