MyHealth Portal Access Request Form

Southeastern Ohio Medical Center

MyHealth Portal Access Request
Thank you for your interest in Southeastern Medical Center MyHealth Portal, a web-based patient portal that provides you with secure and convenient access to your health information. This request form must be completed for access to our MyHealth portal.

Southeastern Ohio Regional Medical Center is now OhioHealth Southeastern Medical Center.
Patient Name*

First NameLast Name
Social Security Number*
Date of Birth*

MonthDayYear
Date
Phone*
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Are you the patient completing this form?*
Parent / Legal Guardian of the patient

Parent / Legal Guardian of the patientLegal Power of Attorney for PatientOther
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
NOTE:
You will be sent an email to complete a Proxy form and/or submit additional Legal documents supporting the request (i.e.: POA, Legal Guardianship, court orders) if you are not the patient completing this form.
Please enter a valid Email Address. Email addresses are required to access the MyHealth Portal.
Email*
Confirm Email*
Submission Date

MonthDayYear
Date
Hour MinutesAM/PM Option
By completing and submitting this form you are certifying that all provided information is complete and accurate.*

Agree
Please verify that you are human*
Should be Empty:

Southeastern Ohio Medical Center