Karmanos Portal Access Request

First Name: *

Last Name: *

Date of Birth: *

Sex: *

Male	Female
Both	Unknown

Address Line 1: *

Address Line 2:

City: *

State: *

Zip Code: *

Phone Number: *

Email Address: *

Please Re-Enter Email Address: *

Additional Identifying Information: *

MRN	Date of Service
SSN	I do not have

Patient MRN: *

Patient Date of Services: *

Patient SSN: *

Challenge Question: *

Challenge Question Answer: *

I hereby affirm that I am the patient identified above and I understand that submitting false information might lead the revocation of my access to Karmanos HealtheLife Portal. I also understand that I am requesting access to my own chart and my parent/guardian may have limited access to my records including allergies, immunizations, direct messages and appointments.

Confirm

Last four of your SSN	Year you got married
Year you graduated high school	Year your father graduated high school
Year your father was born	Year your mother graduated high school
Year your mother was born	Your postal code

Teen Self Registration Access Request to Karmanos HealtheLife Portal