Patient Portal Request Form

Request Patient Portal Access

To request a Patient Portal invitation, please read the consent information and complete the form below. After we receive your form, a hospital representative will call you to validate your identity and complete your request.

Name
Email Address
Patient’s date of birth
Primary Phone Number
I have read the consent information. I also understand a hospital representative will contact me to verify my identity.

Consent Form

User Electronic Mail Authorization Form
FollowMyHealth™ Portal Consent


FollowMyHealth™ Patient Portal

The Iredell Memorial Hospital (“IMH”) Patient Portal (“Portal”) offers patients convenient and secure access to their personal health information. You are in control of your Portal account. IMH will not activate your Portal account unless authorized. This only occurs when you provide your electronic mail (email) address and sign this form. Your decision to provide your email address and sign this form is completely voluntary. If you provide your email address to IMH, please note that IMH may use your email address for other purposes in accordance with applicable law; however, IMH will not share your email address with others.

If you choose not to complete this form, you will not be able to access personal health information from IMH using the Portal. If you complete this form, you consent to have IMH contact you for verification and to email you a unique link. For your protection, the unique link from IMH will expire after 30 days if not used. Once the link expires, you must present in person to the Medical Records Department at Iredell Memorial Hospital for assistance.

You will use the link to create a connection to the Portal. You will need your patient security code to sign up for access to the Portal. Your security code is the last 4 numbers of your primary phone number.

Personal identifying information and other health and medical history information are available via the Portal. Please choose an email address that will not be used or accessed by anyone else. When you first log-on to the Portal, it will prompt you to create a password for your Portal. It is very important to keep your password private. Do not share your password with anyone or write your password in a place easily accessible to others.

Terms

If you provide your email address, you will be contacted to verify your identity, after which you will receive an email with information to access the Portal and authorize IMH to make your personal health information available via the Portal. You are also authorizing IMH to use your email address for other purposes permitted by law. The terms and conditions of the Portal shall apply to this User Electronic Mail Authorization Form.

Please indicate on the form above that you have read and accept the conditions of the consent form by clicking the box above the Submit button.