Portal Access Request | Adult Self Registration

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: *

In order to claim your invitation, you will need to remember your challenge question answer.

Challenge Question: *

Challenge Question Answer: *

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

Access Request for Adult Self Registration to McLaren HealtheLife Portal