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Request for Access

Request for Access

By filling out the following form below, I authorize Rochelle Community Hospital to enroll me and use the information for my RCH health Patient Portal. I also understand there is no expiration date on this authorization unless I present a request to change the expiration date in writing to the Health Information Management Department at Rochelle Community Hospital. Information in my portal may include and is not limited to sexually transmitted diseases, acquired immunodeficiency syndrome/human immunodeficiency virus, behavioral, mental, sexual, drug or alcohol abuse and/or treatments. I understand checking the box at the end constitutes a legal signature. I also understand that I may be subject to penalties under law for any false or misleading information on this application.

Required fields are marked with a ✓

First Name

Middle Initial

Last Name

Last 4 digits of Social Security Number

Date of Birth

Phone Number

Address

City

State

ZIP

Email

Electronic Signature (type your full name)

Spam Check. Please enter the text into the field.