Name: | DOB: | MRN: | PCP:

Online Registration Form

Welcome! Community Health Network is 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 Community Health Network account.

We will mail your activation code to the address above after validating your submission with your Community Health Network account information. Should we have any questions regarding your submission, we will contact you via the home phone number you have submitted.