Mychart Request Form

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Patient Name: ________________________________
MyChart Request Form
Date of Birth: _____________________________________
Medical Record #: _________________________________
MyChart Access Request Form
Place Patient Label
Thank you for your interest in MyChart, an easy-to-use online tool that provides quick and secure online access to your
Rush-Copley health information from anywhere at any time.
Instructions for Completing This Form
To request access to your health information in MyChart, please complete this form and either return it to your doctor’s
office, or the Rush-Copley Health Information Management office via an email to , fax to
630-692-5970, or mail to the following address: Rush-Copley Health Information Management office, MyChart Request,
2040 Ogden Avenue, Suite 313, Aurora, IL. 60504
Once this form is received, your MyChart activation code will be delivered to you by mail or email. To receive your
activation code by email, check the box at the bottom of this form and provide a valid email address. Use the activation
code to sign up for MyChart at rushcopley-mychart.rush.edu.
If you would like online access to your child (under 12) or another adult’s health information, please ask your doctor’s
office for the appropriate MyChart Proxy Request Form or download it at rushcopley-mychart.rush.edu/resources.
Your Information (All sections required – please print clearly.)
This section should be completed by the individual requesting access to their MyChart record.
Name (Last, First, Middle Initial): __________________________________________ Date of Birth: ________________
Email Address:__________________________________ Street Address: _____________________________________
City: _______________________________ State: _____ Zip: ____________ Phone Number: ____________________
MyChart Terms and Agreement
I understand that MyChart is intended as a secure online source of confidential medical information. If I share my MyChart
username and password with another person, that person may be able to view all of my available health information, my
child’s health information, and health information about someone who has authorized me as a MyChart proxy. I agree that
it is my responsibility to select a confidential password, to protect my password, and to change my password if I believe it
may have been compromised in any way.
I understand that MyChart may contain selected, limited information from my medical record, which may include test
results and records related to genetic testing, genetic counseling, drugs and alcohol, HIV, mental health and
developmental disability. I also understand that MyChart does not reflect the complete contents of my medical record
and that a paper copy of my medical record may be requested from Rush-Copley.
I understand that my activities within MyChart may be tracked by a computer audit and that entries I make may become
part of my medical record. I understand that access to MyChart is provided by Rush-Copley as a convenience to its
patients and that Rush-Copley has the right to deactivate access to MyChart at any time for any reason. I understand that
use of MyChart is voluntary and I am not required to use MyChart or to authorize a MyChart proxy. I understand that I can
revoke proxy access to my health information at any time by accessing the MyChart website.
The full MyChart Terms and Conditions can be found at rushcopley-mychart.rush.edu.
By signing below, I acknowledge that I have read and understand this MyChart Request Form and agree to its terms.
Signature of Patient: ________________________________________________
Date: __________________
If you would prefer your activation code delivered to a personal email account, provide the address below.
Email address: ____________________________________________________________
Initials: _______

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