MyHealthChart Support Request Form

notice: Crouse Hospital's MyHealthChart is only for current or any previous Emergency or Inpatient Crouse patients since March 1, 2014. If you have not been a patient with us, we will not be able to provision a MyHealthChart for you.

MyHealthChart is a way for your doctor to securely share limited medical information with you. Your information is only available to you and the people (such as your family) you designate. The purpose is so you can take a more active role in your healthcare and help your doctor take better care of you.

I request access to my health information through MyHealthChart. I understand that MyHealthChart will let me:

See portions of my health information.
Potentially have future access to more types of information and communications.

I understand that by consenting, my medical information will be available to me and anyone I designate through MyHealthChart. I also understand that should I decide I no longer want my medical information to be available on MyHealthChart I need to complete the opt-out form. I understand that after I chose to opt-out my medical information cannot be deleted from the My Crouse Chart database, though it will no longer be viewable online.

	*First Name:	*Last Name:	*SSN (Last 4):
Patient Information	* indicates required fields

	*Date of Birth:	*Phone #:	*Email Address:
		(555) 555-5555

Confirmation	* I have read this form. I agree to be bound by its terms and conditions and those online in the terms of service. In lieu of a signature, by checking this box, I confirm the information I have provided on this form is correct.