Request Activation Form

Patient Portal Support Request

Please do not send personal information, medical information, or medical questions. We cannot reply to medical or scheduling requests through email. If this is a medical emergency, call 911. If you have a medical question, please call us.

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First Name*

Last Name*

Email*

Phone Number*

Date of Birth*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Who will use this account?*

Are you requesting a new patient portal account?*

Please describe your request in detail*

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Phone

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Genesis is proud to be accredited as a Patient Centered Medical Home through the NCQA. Genesis Community Health provides healthcare that is relationship-based that addresses the whole person and their needs. Genesis provides resources for patient education and self-management support. Please speak with your medical provider to obtain the resource list.