Name: | DOB: | MRN: | PCP:

MyChart Activation Code Request: New Patient Account

Thank you for your interest in MyChart, a secure online portal. To request access to your medical record information, please complete the form below. We will contact you by phone if we have any questions regarding the information provided. IMPORTANT: You must be an established patient at Cincinnati Children's in order to request a MyChart account online.

Once your request has been approved, we will send you an activation code through secure email within 7 business days.


Tell Us About You:

*A valid email address is required to request a MyChart account.


IDENTITY VERIFICATION: To ensure that your information is protected and secure, a copy of your driver's license, state or school photo ID will be needed to verify your identity. Proof of identification can be provided using our secure document upload. (A new window will open.) You can also send this information to the Health Information Management (HIM) Department at Cincinnati Children's using secure fax, 513-487-4845. The ID will be used solely to verify identity and will not be permanently stored.



PLEASE READ AND SIGN THIS FORM:

You must read, understand, and agree to the terms described in our Cincinnati Children’s MyChart Agreement Form and the Terms and Conditions of Use posted on the MyChart website before an account can be provided. Violations of these terms may result in loss of access to MyChart. Once you have read each of these documents, please sign this form below.


Sign this form electronically by clicking the box to the right