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©2015 Austin Regional Clinic | MyChart is a registered trademark of Epic Corporation | 07212017
Adult Registration Form
(18 years or older)
Thank you for your interest in MyChart
®
, an easy-to-use Internet tool that provides you quick and secure online access to
your Austin Regional Clinic health information from anywhere at any time. Follow the 3 easy steps below:
1. Complete Form
To Access your child or another adult’s MyChart information, ask your clinic for the appropriate forms or download them
from http://bit.ly/MyChartForms.
2. Affirm Your Identity
I hereby affirm 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 application to access the MyChart service.
Signature of Patient Date (required)
3. Submit Completed Form (Three ways to submit your form)
In Person:
Return the completed form to the
front desk at your ARC clinic.
Mail to:
Austin Regional Clinic
MyChart Support
PO Box 26726
Austin, TX 78755-0726
Fax to:
512-421-5626
FOR CLINIC USE ONLY:
MyChart Access Granted by:_____________________ Clinic/Department Name:_______________________ Date:____________
Information Release by: __ Clinic/Department Name:_______________________ Date:____________
YOUR INFORMATION: ***ALL FIELDS REQUIRED*** Please print clearly.
Last Name: First Name: Middle Initial:
ARC Medical Record Number (acquire at clinic): Date of Birth:
Street Address: City: State: Zip:
Email Address: Best Phone Number:
Primary Clinic:
Please sign and date forms prior to forwarding to EMR-Scanning at I-35
