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MyChart - Patient Portal Sign-up Information:

Use this form to request a MyChart account. Please fill out the form as completely as possible. If you do not know your Account Number or Medical Record Number, leave the field blank and a CMH representative will contact you to complete your MyChart registration. Once you have been registered for the MyChart, you will receive an email from mychart@citizensmemorial.com with instructions to complete your account registration.

Proxy access must be requested in person at a CMH Clinic or the Health Information Management department at the hospital. The patient granting proxy access to their account must present picture identification in accordance with HIPAA regulations.

Name
Social Security Number A value is required.Invalid format.
Address
City
State
Zip
Phone A value is required.Invalid format.
Date of Birth A value is required.Invalid format.
Email Address A value is required.Invalid format.
Preferred Username

Account Number or Medical Record Number

How did you find out about the CMH Patient Portal?
Other:
Today's Date A value is required.Invalid format.
This form will be securely routed to CMH. You may be contacted by a CMH Representative to confirm your identity and that you requested access to your medical record via the CMH Patient Portal.