Add Portal Request

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Portal Activation / Support Request

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• 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 *

  01 02 03 04 05 06 07 08 09 10 11 12

• Date of Birth Day *

  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

• Date of Birth Year *

  2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

• Phone *

  ext.

• Email Address *

• Confirm Email Address *

• Please enter your email address

Signature

• 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 *
• Notice of Privacy Practices

Status

• Completed By

  Ban-Ira, Ernest Espinal, Romel Foster, Tyler Frias, Rosanna Gager, Kate Juniet, Betty Kressbach, Hannah LaBella Roman, Alexis Macri, Giuseppe Magana, Nallely Marsh, Eugene Patel, Ronak Stevens, Kevin Sullivan, Karen Teyssedou, Angelia Valle, Joceline

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