This form is used to confirm that the provided email is correct and will reach the intended recipient. Please provide your child(ren)'s names that you are requesting access for. A temporary password for access to the patient portal will be sent to this address after confirmation. In addition,  the email provided will be used to send forms, invoices and other requested records in a HIPAA compliant way. If you agree to use email to receive HIPAA sensitive health information, make sure you type ACCEPT in the appropriate field below.
* indicates required
Please use the health insurance user ID number we have on file for your child(ren)
Type in ACCEPT if accept. We will be using the provided and confirmed email to send HIPAA sensitive health information like requested forms, invoices and records.