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If an account has not been created in the allowable time period your patient portal access will be disabled. Edinger Medical Group is offering this secure HIPPA compliant MyEMGChart patient portal as a courtesy to our patients. You also agree not to hold Edinger Medical Group or any of our staff liable for network infractions beyond their control. MyEMGChart patient portal has a secure tunnel connection with our clinic that uses encryption to keep unauthorized persons from being able to access and read your health information or communications from us. Patient Portal Enrollment Form MyEMGChart Last Name First Name MI Date of Birth // Preferred Contact Phone Number Home Phone Cell Phone Work Phone Preferred email address for portal account Portal Features Send and receive messages from your doctor or support staff View laboratory results Request appointments View upcoming appointments View referrals Initial By completing and signing this form you agree to access and create a portal account within 14 days of receipt of user name and password. It is an optional service that we reserve the right to suspend or terminate at any time. We will alert you to any changes as promptly as possible. This consent is intended to inform you of the facts and risks surrounding the use of the web portal* By acknowledging below you have confirmed that you have read understand and agree to comply with our procedures and guidelines for using MyEMGChart. To help insure that this system remains secure we need to have your current PRIVATE email address and be informed if it ever changes. Keep your MyEMGChart username and password secure so only you or someone authorized by you can gain access to your patient information* If you think someone has learned your password immediately go to the portal site and change it. It is your responsibility to protect your password and login* Electronic Signature I Accept Date SUBMIT TO EMG your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting I Accept you consent to the Portal Agreement terms and conditions. Office Use Form Accepted by Web Enabled by Verify within 14 days Acct Verified Scanned and noted by Web Disabled by Acct NOT Activated T/E to MR for Mailing MR mailing verified/sent No Mail -- No info to send. It is an optional service that we reserve the right to suspend or terminate at any time. We will alert you to any changes as promptly as possible. This consent is intended to inform you of the facts and risks surrounding the use of the web portal* By acknowledging below you have confirmed that you have read understand and agree to comply with our procedures and guidelines for using MyEMGChart. To help insure that this system remains secure we need to have your current PRIVATE email address and be informed if it ever changes. Keep your MyEMGChart username and password secure so only you or someone authorized by you can gain access to your patient information* If you think someone has learned your password immediately go to the portal site and change it.

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