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Patient Information

We need some information to grant you a MyChart account. After you submit this request, it may take up to a week for processing and verification. When you're approved, you will receive an email or a letter with your activation code and instructions on how to activate your MyChart account. If you have any questions, please contact us at (555) 555-5555.

Follow these steps to sign up for a MyChart account.

Enter your personal information.
Verify your contact information.
Choose a username and password.

If you have any questions, please contact us at (555) 555-5555.

Follow these steps to sign up for a MyChart account.

Enter your personal information.
Verify your identity.
Choose a username and password.

If you have any questions, please contact us at (555) 555-5555.

FOR NEW ACCOUNTS ONLY: Use this form to register for a new MyChart account. If you have an existing account and do not remember your username or password, use the Recover Your Username or Password Reset forms for assistance. If you already have an activation code, you’ll want to sign up from our MyChart Signup Page.

INSTRUCTIONS: Complete the fields in the form below. If the information you provide matches our records, you will receive a MyChart activation code by email shortly after you submit the form. If we cannot match your information, a support representative will contact you by email in 2-4 business days with further instructions. Note that you must be an existing Lee Health patient 18 years or older to have an account.

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Name

First name

Middle name

Last name

Address

Other Information

Date of birth

Home phone

Mobile phone

Work phone

Legal sex

FemaleMaleUnknown

Social Security number

Email address

Verify email address

Thank you - your request has been sent to the clinic. You will receive an activation code in your mail or email within a week.

If you have any questions or if you do not receive your activation code, call customer service.

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We were unable to verify your information, so your request has been sent to MyChart support. You will be contacted by email within a week.

If you have any questions or if you do not receive your activation code, contact support.

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We are experiencing technical difficulties at this time. Please try again later or contact our customer service line for assistance.

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We were unable to verify your identity using the information provided. Please contact customer service at (555) 555-5555 for assistance.

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We are experiencing technical difficulties at this time. Please contact our customer service line for assistance.

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Our records indicate that you already have a MyChart account. If you not remember your username or password, use the Recover Your Username or Password Reset forms for assistance.

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There is an existing account for this person.

Please contact us directly to restore access to your account.

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We are experiencing technical difficulties at this time. Please try again or contact our customer service line for assistance.

Unable to complete MyChart signup. Please contact customer service at (555) 555-5555 for help activating your account.

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In order to grant you a MyChart account, we will verify your identity using questions from a third-party verification system. Once verified, you will be able to create your MyChart account. If you have any questions, please contact your clinic.

We are checking with a third-party system to verify your identity. This may take several seconds.

Unable to Verify Your Identity

We are unable to verify your identity using the information provided. Please fill out a Technical Support Form on the MyChart Support Page and a support representative will follow up with you in 2-4 business days.

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Unable to Verify Your Identity

We are experiencing some technical difficulties while communicating with the third-party verification system. Please contact our customer service line for assistance.

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As an extra layer of security, Lee Health has partnered with Experian and their Precise ID verification system. The following questions are generated from Experian's records and are used to further validate your identity and help Lee Health provide you secure access to your medical record.

These questions are unique to you and come from a credit database.
Answering these questions will have absolutely no impact on your credit score or history.
We do not record or store the information in any capacity.
We only use the information to verify your identity for this MyChart request.

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