Demographic Information

  • About me

    Full Name: -

    Date of Birth: -

    Gender: -

    Marital Status: -

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    Ethnicity: -

    Contact Information

    Address: -

    Email: -

    Home Phone: -

    Daytime Phone: -

    Cell Phone: -

Insurance Information

My Insurance List

  • Insurance name

    Insurance Information

    Card Holder Name:

    Insurance Company:


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    Subscriber Information

    Relation with Card Holder:

    Date of Birth:



Insurance Information

All fields below marked with an asterisk (*) are required.

Subscriber Information

Pending Insurance Information

Relative Account Profile

Full Name: -

Date of Birth: -

Email: -

Contact Phone: -

Address: -

Manage Sharing My Health Record

You can authorize family members to view your medical records and contact clinic staffs via secure messaging. You can discontinue any authorized access and reassign new PIN for a pending access.

Father: Jimmy Fallen []

DOB: 12/21/1957 - Phone: 310-232-1122

waiting for relative confirmation

Authorize a Relative

Provide the following information to authorize your family member view your medical record. An email will be sent with a link and instructions on how to complete the process.

Please keep a record of the 4-digit PIN number you set, your family member will need it for the first access to your medical record.

Available Medical Records

Daughter: Jimmy Fallen (DOB: 10/22/1991)

Contact Phone: 310-232-1122

Active access from 10/11/2012 to 10/15/2015

Pending Medical Records

Father: Jimmy Fallen

authorize on 10/11/2012



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Security Questions

Activity History