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

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Last 4 digits of Social Security Number *

Date of Birth *

Date

Time

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

Email *

Signature *

Clear Signature

Comments/Questions

Submit