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Get Dupage Medical Group My Chart

Mychart. dupagemedicalgroup.com. Return forms to your clinic or to DuPage Medical Group HIM Department 430 Pennsylvania Avenue Glen Ellyn IL 60137 or fax to 630-324-2933. DuPage Medical Group WE CARE FOR YOU SIGN-UP FORM Thank you for your interest in MyChart an easy-to-use online tool that provides you quick and secure online access to your DuPage Medical Group health information from anywhere at anytime. Instructions for Completing this Form To sign up for access to your health information in MyChart please complete this Sign-Up Form and return it to your clinic or to the address shown below. If you would like access to your child or another adult s MyChart information please ask your clinic for the appropriate forms or download them from www. Your Information All sections required please print clearly. Name last first middle initial Date of Birth Last 4 Digits of Social Security Number Email Street Address City Phone Number Primary Physician Patient s full SSN must be on file with DMG to activate a MyChart account State Zip MyChart Terms and Agreement I understand that MyChart is intended as a secure online source of confidential medical information* If I share my MyChart ID and password with another person that person may be able to view my or my child s health information and health information about someone who has authorized me as a MyChart proxy. I agree that it is my responsibility to select a confidential password to maintain my password in a secure manner and to change my password if I believe it may have been compromised in any way. the medical record. I also understand that a paper copy of a patient s medical record may be requested from the patient s clinic* access to MyChart at any time for any reason* I understand that use of MyChart is voluntary and I am not required to use MyChart or to authorize a MyChart proxy. the other provider as both providers jointly share MyChart. By signing below I acknowledge that I have read and understand this MyChart Sign-Up Form and I agree to its terms. Signature of Patient Date Required 6/12v*1 MyChart is a registered trademark of Epic Systems Corporation. Instructions for Completing this Form To sign up for access to your health information in MyChart please complete this Sign-Up Form and return it to your clinic or to the address shown below. If you would like access to your child or another adult s MyChart information please ask your clinic for the appropriate forms or download them from www. Your Information All sections required please print clearly. Name last first middle initial Date of Birth Last 4 Digits of Social Security Number Email Street Address City Phone Number Primary Physician Patient s full SSN must be on file with DMG to activate a MyChart account State Zip MyChart Terms and Agreement I understand that MyChart is intended as a secure online source of confidential medical information* If I share my MyChart ID and password with another person that person may be able to view my or my child s health information and health information about someone who has authorized me as a MyChart proxy. I agree that it is my responsibility to select a confidential password to maintain my password in a secure manner and to change my password if I believe it may have been compromised in any way.

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