Name: | DOB: | MRN: | PCP:

Request a My K-Chart Activation Code

Your My K-Chart activation code and login instructions will be sent to the email address provided below within one to three business days. You will use this code to create a My K-Chart ID and password. You will use this ID and password to view medical, account and other information in your My K-Chart account.

Please be sure that your email is confidential and secure and can be viewed only by you. This will protect your personal health information.

If your request is not accepted during the validation process, you will be notified by letter.

The information that you provide must match what is currently listed in your electronic medical record. The information is confidential and will be processed through secure internet servers. To continue with the registration process, please read the My K-Chart Terms and Conditions statement.

* indicates a required field

 (XXXXX)(XXX-XXX-XXXX)(MM/DD/YYYY)(XXXX) Your SSN must be loaded into your electronic medical record in order to use this form. Your email address must be valid in order to process this request.
*Check All