Patient Portal Access Request – The Community Health Center Of Lubbock

Name *

First

Last

Date of Birth *

Phone Number *

Email *

Email

Confirm Email

Your e-mail address will be your log in name. Once we have created your account you will receive an e-mail with the link to the portal. Please allow 24-48 business hours for us to process your request. You will be asked to create your own password once you enter the portal for the first time.

Patient Name #1

First

Last

Date of Birth

Authority

If you are the legal guardian or have power of attorney for a family member or friend, you may also have access to their portal. We must have proper documentation on file to grant these requests. Please give us the following information for any additional patients for whom you would like viewing access. Note: If we do not have proper documentation on file to view additional patients they will not show when you log into your portal. You will need to contact our office and provide the required documentation.

Patient Name #2

First

Last

Date of Birth

Authority

If you are the legal guardian or have power of attorney for a family member or friend, you may also have access to their portal. We must have proper documentation on file to grant these requests. Please give us the following information for any additional patients for whom you would like viewing access. Note: If we do not have proper documentation on file to view additional patients they will not show when you log into your portal. You will need to contact our office and provide the required documentation.

Patient Name #3

First

Last

Date of Birth

Authority

If you are the legal guardian or have power of attorney for a family member or friend, you may also have access to their portal. We must have proper documentation on file to grant these requests. Please give us the following information for any additional patients for whom you would like viewing access. Note: If we do not have proper documentation on file to view additional patients they will not show when you log into your portal. You will need to contact our office and provide the required documentation.

Please call 806-765-2611 if you have any questions or need help navigating the portal.