NRHS Patient Portal Requests

Request Category

Portal Reset

Portal Enrollment

Portal Question

I request that my Covid results be emailed to me in a secure email

I wish to Opt out of Common Well

Patient Name

Please enter First and Last name

Name (if different from patient)

Relationship to Patient

DOB

mm/dd/yyyy

Patients Last Four of Social Security Number

Phone Number

Please list phone number in the event we need to contact you directly. xxx-xxx-xxxx

Phone

Most Recent Visit (Month/Year)

Email

Medical Record Number if Known

Should be in the format of E followed by 9 numbers. Example: E123456789