Affirmation
I hereby affirm that I am the patient identified above. I understand that I may be subject to penalties under law for submitting false or misleading information in connection with this request to access MyChart.

By submitting this form I agree to allow Essentia Health and its independent Community Connect customers to release my personal health information to me via an online MyChart account. I will be able to access information maintained in MyChart for my personal use.

• This authorization will be valid for as long as I maintain an active MyChart account.
• If I change my mind and no longer want MyChart access, I may let Essentia Health or its independent Community Connect customers know in writing at any time. This change will become effective no later than the next business day after the date that the request is received and will not apply to information that has already been released before this effective date.
• Essentia Health and its independent Community Connect customers cannot be responsible for the confidentiality of information released to me, and cannot prevent me from releasing the information to another person. At that time, the information is no longer protected by federal and state privacy regulations.
• If I do not create a MyChart account, I will still be treated and payment, enrollment and eligibility for benefits will not be impacted.
• I designate my MyChart account as my preferred method of communication to receive reminders about preventive and follow-up care (excludes scheduled appointment reminders).
• As part of this on-line account creation process I will be asked to confirm that I have read and agree to the MyChart Terms and Conditions for Essentia Health and its independent Community Connect customers. I understand that every time I use MyChart I agree to these Terms and Conditions.

By clicking "AGREE & SUBMIT" I confirm that I have read and agree to the terms of this authorization. I acknowledge that I am electronically submitting this authorization on my own behalf. I understand that I may be subject to penalties under law for submitting false or misleading information in connection with this authorization.

Affirmation
I hereby affirm that I am the patient identified above. I understand that I may be subject to penalties under law for submitting false or misleading information in connection with this request to access MyChart.

By submitting this form I agree to allow Essentia Health and its independent Community Connect customers to release my personal health information to me via an online MyChart account. I will be able to access information maintained in MyChart for my personal use.

• This authorization will be valid for as long as I maintain an active MyChart account.
• If I change my mind and no longer want MyChart access, I may let Essentia Health or its independent Community Connect customers know in writing at any time. This change will become effective no later than the next business day after the date that the request is received and will not apply to information that has already been released before this effective date.
• Essentia Health and its independent Community Connect customers cannot be responsible for the confidentiality of information released to me, and cannot prevent me from releasing the information to another person. At that time, the information is no longer protected by federal and state privacy regulations.
• If I do not create a MyChart account, I will still be treated and payment, enrollment and eligibility for benefits will not be impacted.
• I designate my MyChart account as my preferred method of communication to receive reminders about preventive and follow-up care (excludes scheduled appointment reminders).
• As part of this on-line account creation process I will be asked to confirm that I have read and agree to the MyChart Terms and Conditions for Essentia Health and its independent Community Connect customers. I understand that every time I use MyChart I agree to these Terms and Conditions.

By clicking "AGREE & SUBMIT" I confirm that I have read and agree to the terms of this authorization. I acknowledge that I am electronically submitting this authorization on my own behalf. I understand that I may be subject to penalties under law for submitting false or misleading information in connection with this authorization.