Howard County Medical Center : Patient Portal : Patient Portal

If you would like to access the portal for someone other than yourself, this form needs to be completed and returned to our Medical Records department.
Download Patient Proxy Form

First Name *REQUIRED

First Name

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Last Name *REQUIRED

Last Name

Middle Intial

Email Address *REQUIRED

Email Address

Phone Number

Date of Birth *REQUIRED

Last 4 digits of your social security number *REQUIRED

Last 4 digits of your social security number