Add Portal Request

  • *

Portal Activation / Support Request

  • Thank you for your interest in the CHC patient portal!

    Please complete the information below and a member of our portal team will be happy to assist you as soon as possible.

    We are not currently providing patient portal accounts to patients aged 11-17 years old due to privacy regulations. If you have any questions regarding this, please contact the Health Information Management department at (860) 347-6971 x4161.

Personal Information

  • If this is a request for your child UNDER the age of 11 years old, please fill the following out with the child's information.
  • First Name *

  • Last Name *

  • Date of Birth Month *

  • Date of Birth Day *

  • Date of Birth Year *

  • Phone *

  • Please enter your email address


  • By typing my name and date below, I am providing my signature and certifying that I have read the above information and the information that I have provided to the Community Health Center, Inc. is true to the best of my knowledge. I will notify you of any changes.
  • Please allow 2-3 business days after you fill out this form to be able to access your patient portal account. You will receive an email to the address provided with login information. If you are experiencing an urgent medical issue or need an appointment, please call us at 860-347-6971.
  • Signature *

  • Date *


  • Completed By