Demographic Information

  • About me

    Full Name: -

    Date of Birth: -

    Gender: -

    Marital Status: -

    Preferred Language: -

    Race: -

    Ethnicity: -

    Contact Information

    Address: -

    Email: -

    Home Phone: -

    Work Phone: -

    Cell Phone: -

Insurance Information

My Insurance List

  • Insurance name

    Insurance Information

    Card Holder Name:

    Insurance Company:

    Group:

    Policy Number:

    Contact Phone:

    Subscriber Information

    Relation with Card Holder:

    Date of Birth:

    Address:

    Phone:

Insurance Information

All fields below marked with an asterisk (*) are required.

Subscriber Information

Pending Insurance Information

Relative Account Profile

Full Name: -

Date of Birth: -

Email: -

Contact Phone: -

Address: -

Manage Sharing My Health Record

You can authorize famlily members to view your medical records and contact clinic staffs via secure messaging. You can discontinue any authorized access and reassign new PIN for a pending access.

Authorize a Relative

You need to provide the following information below to authorize your family member view your medical record. If he/she is not in the network, a system email will send out with a link.

Please keep a record of the 4-digit PIN number you set, your family member will need it for the first access to your medical record.








Available Medical Records

Pending Medical Records

My Clinic

Address:

Office Hours:

Phone:

Security

Login Information

User ID:

Password:**************

Security Questions

Activity History