New Froedtert South MyChart activation code request

Froedtert Health Inc. (“FH”) and the Provider Organizations listed below share an electronic health record system for documenting patient care, scheduling appointments and other tasks. MyChart® is an easy-to-use online tool providing the patient (“you”) or the your designated proxy with quick and secure access to a number of features, including to see your appointments, medications, lab test results and other limited information from your medical record. For more information about MyChart®, go to MyChart.

FH furnishes MyChart for the patients of the following organizations and their respective subsidiaries and other affiliates that use FH’s Epic electronic health record system (“Epic EHR System”) (collectively, the “Provider Organizations”, and together with FH, “we”, “us” or “our”):

• Froedtert Memorial Lutheran Hospital, Inc., Community Memorial Hospital of Menomonee Falls, Inc., St. Joseph’s Community Hospital of West Bend, Inc., Froedtert & The Medical College of Wisconsin Community Physicians, Inc., West Bend Surgery Center, Froedtert Surgery Center, LLC, Drexel Town Square Surgery Center, LLC, Menomonee Falls Surgery Center, LLP, Inception Health, LLC, Wisconsin Diagnostic Laboratories, LLC and certain other affiliates of FH (collectively, “FH Affiliates”);

• The Medical College of Wisconsin, Inc. (“MCW”); and

• Certain other organizations that contract with FH for the right to use FH’s Epic EHR System in their healthcare facilities, physician offices and other locations. For more information about FH and the Provider Organizations, please visit

You may request a MyChart® account with us for yourself by completing this online MyChart® Account Request Form. You may also request an account by visiting FH or your Provider Organization and signing a paper form.

CAUTION: You must be able to answer "yes" to each of the following statements in order to submit this MyChart Account Request Form:

1. You are requesting access for yourself.

2. You are at least 18 years old.

3. You are interested in seeing portions of your protected health information stored by your Provider Organization(s).

If you are not able to answer "yes" to each of the above statements, you are not able to submit this MyChart Account Request Form.

Medical records and other information available through your MyChart® account result from your treatment by FH Affiliates and other Provider Organizations and their physicians and other workforce members.

In addition, we have agreed to exchange MyChart® records with certain healthcare providers that are not Provider Organizations (“MyChart-Only Providers”). In those cases, your MyChart® account will also let you access your records from the My-Chart Only Providers from which you have received treatment.

The information you find in MyChart® is protected health information (PHI) under HIPAA. The FH Affiliates and MCW use and disclose your PHI in accordance with the Joint Notice of Privacy Practices available at or by request. You may request the other Provider Organizations’ Notices of Privacy Practices from the Provider Organizations.

MyChart® Terms: Please review the MyChart® Terms & Conditions set forth at You will need to agree to the MyChart® Terms & Conditions upon account activation in order to use MyChart®.

By clicking "Submit" below, you acknowledge that you have read and understand this MyChart Account Request Form and you agree to its terms. You also certify that all information you have provided is current, and correctly identifies you.

Contact Information: