Patient Portal Header

Patient Portal Sign-up Information:

Use this form to request a CMH Patient Portal account. Once you have been registered for the CMH Patient Portal, you will receive an email from mychart@citizensmemorial.com with instructions to complete  your registration.

Proxy access may be requested in person at any CMH facility or by telephone at (417) 328-6304. The patient granting proxy access to their account must verify the request.

First Name
Middle Initial
Last Name
Last 4 digits of Social Security Number A value is required.
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.
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.