Name: | DOB: | MRN: | PCP:

Activation Code Request

Welcome! Your activation code will be your key to your personal and secure electronic medical record. Please fill out the fields to verify your identity. If you have activated your MyChart account previously and cannot access your account with your current name and password or have forgotten them, please go to the main MyChart page and use the forgot username or forgot password links or call MyChart support at 1-855-694-6682 (1-855-MYINOVA).

We will email your activation code to the email address we have on file after validating your submission. Should we have any questions regarding your submission, we will contact you via home phone or email.