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MiCare Registration Form First Name Last Name Date of Birth MM/DD/YYYY Your SSN -- Home Zip Code Gender circle one Male Female E-Mail Address Provider/Primary Care Manager This information is subject to the Privacy Act of 1974 5 U.S.C. MICARE REGISTRATION FORM MICARE FACTS AND REGISTRATION MiCare Facts What is MiCare MiCare is a user-friendly confidential online healthcare messaging system that allows patients to communicate with their healthcare team get test results request prescription refills and maintain their own personal health record. This ensures that your information and messages are only accessible by you and your healthcare team. In addition MiCare is in compliance with the Health Information Portability and Accountability Act of 1996 HIPAA. How do I register Fill out the registration form below and return it to your Medical Treatment Facility MTF. In the future information from your electronic health record will be available to transfer directly into your personal health record. Who can use MiCare MiCare is scheduled for implementation Air Force wide. That means that once patients have registered they will remain in the system* When PCS-ing your account will travel with you so you are able to connect with your new clinic at your new duty station* Is my privacy protected When using MiCare a secure connection is established with the browser to validate that your personal information is encrypted and coded for transmission and storage. This ensures that your information and messages are only accessible by you and your healthcare team* In addition MiCare is in compliance with the Health Information Portability and Accountability Act of 1996 HIPAA. How do I register Fill out the registration form below and return it to your Medical Treatment Facility MTF. An MTF staff member will verify your identity using your military ID card. Following the in-person submission of your registration you will receive an email asking you to complete the registration process online. Section 552a January 30 2012 CLINIC USE ONLY Patient ID Verified Date Staff Initials E-mail Invitation Sent. In the future information from your electronic health record will be available to transfer directly into your personal health record. Who can use MiCare MiCare is scheduled for implementation Air Force wide. That means that once patients have registered they will remain in the system* When PCS-ing your account will travel with you so you are able to connect with your new clinic at your new duty station* Is my privacy protected When using MiCare a secure connection is established with the browser to validate that your personal information is encrypted and coded for transmission and storage. Who can use MiCare MiCare is scheduled for implementation Air Force wide. That means that once patients have registered they will remain in the system* When PCS-ing your account will travel with you so you are able to connect with your new clinic at your new duty station* Is my privacy protected When using MiCare a secure connection is established with the browser to validate that your personal information is encrypted and coded for transmission and storage. This ensures that your information and messages are only accessible by you and your healthcare team* In addition MiCare is in compliance with the Health Information Portability and Accountability Act of 1996 HIPAA.

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