Patient Portal Enrollment - CommWellHealth

ATTENTION PLEASE READ BEFORE COMPLETING:

This form is for MyChart patient portal enrollment requests only and already an established patient of CommWell Health.

Do not use this form to request an appointment.
Appointment requests submitted through this form will not be processed.
To schedule an appointment, call 1-877-935-5255.
After your MyChart account is activated, you may be able to schedule eligible appointments online through MyChart.

"*" indicates required fields

First Name*

Last Name*

Primary Phone Number*

Email Address*

Date of Birth*

Address*

Street Address City State / Province / Region

Postal / Zip Code*

Preferred Method of Contact*

Who will use this account?*

Are you requesting a new patient portal account?*