Community Hospital’s MyHealth Portal - Request For Access

Thank you in advance for your interest in Community Hospital’s MyHealth Portal, a web-based patient portal that provides you with secure and convenient access to your health information. Please fill out the form below for access to the MyHealth@CommunityHosp Patient Portal.

First Name*

Middle Initial

Last Name*

Social Security Number (last 4 digits)*

Date of Birth*

Address*

Address Line 2

City*

State*

Zip*

Email*

Confirm Email*

Phone Number*

A valid email address is required in order to use the Patient Portal. Please provide a current, personal and private/non-shared email address that only you have access to and verify its accuracy. By providing an email address, you agree to have the Patient Portal service communicate with you regarding the Patient Portal via email. Absolutely no protected health information will be included in any email communications from the Patient Portal System. In order to protect your privacy, the temporary password and user ID that will be sent to you via your email address will expire in 14 days. If you choose not to access your Patient Portal during this timeframe, please contact Patient Portal Support at 970-644-4002 to reissue a new temporary user name and password.

By checking this box, I acknowledge that I am requesting access to my health information in the Patient Portal. I understand that access to the patient portal will not expire unless I notify the Patient Portal service in writing to discontinue portal access. I understand that the information in my health record may include information related to sexually transmitted disease, and acquired immunodeficiency syndrome/human immunodeficiency virus. It may also include information related to behavioral or mental health services and treatment for alcohol/drug abuse if present in my record.*

I hereby affirm that I am the patient identified above. I understand that I may be subject to penalties under law for submitting false or misleading information in connection with this application to access the Patient Portal service.*

Signature (type full name)*