MyChart -

Welcome! Reliant Medical Group is pleased to offer this online request service for your MyChart account activation code. Your activation code will be your key to accessing your personal and secure online health connection. Please fill out all required fields (*) to verify your MyChart enrollment.

You must be 18 years or older to use this form request a MyChart Account. To request a MyChart account for someone else (called a proxy account), please call or visit their Reliant office for help.

If you already have an active MyChart account and have forgotten your ID or password please return to the log in page and click on the “Forgot MyChart ID” or “Forgot Password” which are located under the login boxes to retrieve the information. For additional assistance please contact us at mychart@reliantmedicalgroup.org or 1-774-261-1292.

*First Name:

*Last Name:

Middle Initial:

Suffix:

*DOB(xx/xx/xxxx):

*Sex:

*Last Four digits of SSN:

*Mailing Address:

*City:

*State:

*Zip Code:

*Primary Phone(xxx-xxx-xxxx):

*Email Address:

Is this MyChart account needed to have a VirtualCare Team appointment within 24 hours?

YesNo

*How would you like to receive your activation code?

PCP Name:

*Affidavit:

By checking this box I hereby affirm that I am the patient identified above. I understand that if I submit false or misleading information in connection with this application to access the MyChart service, I will be subject to penalties under Federal and state law.

We will email your activation code to the email address above after validating your submission with your Reliant Medical Group patient information. Should we have any questions regarding your submission, we will contact you via email.

Activation Code Request