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.

Family Access: If you would like to request access to a family member's MyChart information you can send a request after logging in to your MyChart account. After logging in to MyChart you will find this option under the Messaging tab.

MyChart Terms and Conditions


  • I understand that MyChart is intended as a secure online source of confidential medical information. If I share my MyChart user ID and password with another person, that person may be able to view my health information.
  • I agree that it is my responsibility to select a confidential password, to maintain my password in a secure manner, and to change my password if I believe it may have been compromised in any way.
  • I understand that MyChart contains selected, limited medical information from a patient's medical record and that MyChart does not reflect the complete contents of the medical record. I also understand that a paper copy of a patient's medical record may be requested from the patient's clinic.
  • I give my consent for CentraCare Health and Affiliates to release all information, as defined in the MyChart Terms and Conditions, to the MyChart Account so that I may view this information online.
  • I understand that my activities within MyChart may be tracked by computer audit and that entries I make may become part of the medical record.
  • I understand that access to MyChart is provided by CentraCare Health and Affiliates as a convenience to its patients and that CentraCare Health and Affiliates have the right to deactivate access to MyChart at any time for any reason. I understand that use of MyChart is voluntary and I am not required to use MyChart or to authorize a MyChart proxy.
  • I understand that once information is released pursuant to this authorization, CentraCare Health or Affiliates cannot prevent the re-disclosure of the information to another third party.
  • I understand this authorization must be filled out completely and signed and dated in order to be considered valid. A copy that has not been altered will be considered as valid as an original.
  • I understand that this consent will remain in effect until I provide CentraCare Health or Affiliates with a written request for revocation.
  • By clicking Submit below, I acknowledge that I have read and understand this MyChart Terms and Conditions and I agree to its terms.
  • As a spam prevention measure, complete the CAPTCHA below.

    Based on the information you provided, we will e-mail or text you a link to sign up for MyChart. Please allow 1-2 business days for these requests to be processed. Should we have any questions regarding your submission, we will contact you via the home phone number you have submitted. Please also note, these links are only valid for 24 hours, after which they will expire and you will need a new link.