MyChart Access Request

Allina Health and affiliated partners are located in Minnesota and western Wisconsin.

To sign up for your individual MyChart account, please fill out the information below and click "send". The email address you provide must match an email address in your electronic health record. If we have problems validating your request, you may receive a letter requesting more information. The information is confidential and will be processed through secure Internet servers.

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

After receiving your completed form, we will send instructions and an activation code to your email address. Follow the instructions to create a confidential MyChart user ID and password that you will use to view information in your MyChart account.

Please read the MyChart Terms and Conditions.

* indicates a required field.

* First name
* Last name
MI
* Date of birth (mm/dd/yyyy)
* Last four # of SSN (xxxx)
Must be registered (at Allina Health or an affiliated partner) with a valid and current email address 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 the MyChart service. * 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.