MyChart individual account online sign up

To use this online sign up, for a free MyChart account, you need to:

• be 18 years old
• received care at Allina Health or an affiliate partner health system in Minnesota or Wisconsin
• have a valid email address in your electronic health record

To complete this online sign up, the email address you provide below must match the email address on record in your electronic health record. If we have problems validating your request, you may recieve a letter requesting more information.

After receiving your completed form, we will email you an activiation code and instructions for completing the sign up.

* indicates a required field.

* First name

* Last name

MI

* Date of birth (mm/dd/yyyy)

* Last four # of SSN (xxxx)

A valid and current email address must be on file with an affiliated partner of Allina Health to process your request

* Email address

* Re-type email

* Primary phone (xxx-xxx-xxxx)

* Street address

* City

* State

* Zip code

* Primary clinic

* 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 related to this application to access MyChart.
* I understand the information I provide on the form is used only to confirm my identity. Updates to information on this form will not be made to my medical record.
* I understand it is my responsibility to keep my personal email account and MyChart information confidential and secure.
* I have read the MyChart terms and conditions.