Request Patient Portal Access! Please fill in and submit the YourHealthFile® PATIENT PORTAL ACCESS REQUEST form below. We need this information to verify your identity and help protect your health information. We look forward to better communicating with you about your health online. NOTE: The information entered in all fields must match the information in your Medical Record in order to authenticate you as a patient in our practice. NOTE: The YourHealthFile® Patient Portal should only be used for routine and non-urgent matters. If you are experiencing a medical emergency, please call 9-1-1 NOTE: If applicable, enroll as a PROXY REPRESENTATIVE when caring for a loved one or minor. Alternately, if you would like to grant Proxy access to a: Relative, Caregiver, or Legal Guardian, just fill out and return the Patient Portal Proxy Authorization FormName*Must match your medical record First Last Date of Birth*Must match your medical record DD slash MM slash YYYY Insurance Carrier*Must match your medical record Last 4 digits of SSN*Please enter the last 4 digits of your SSN for ID VerificationXXX-XX-Mobile Phone*Please enter the phone number that you have on file with Family Medicine Associates. It must be a Mobile No. able to receive SMS Text Messages AND match phone on file with Family Medicine Associates.Email* Enter Email Confirm Email Signature*CAPTCHA
