CCPRC Patient Portal Request Form

  Please complete the below form to request access to the CCPRC Patient Portal. Once you complete the form,
  you will receive an e-mail notification with your user name and password to be able to log into the portal.

  Please remember that this portal is not for urgent medical needs.
  If you are experiencing a medical emergency, please call 911 or go to the nearest emergency room immediately.

  Who Is Eligible?

  The CCPRC Patient Portal is available to anyone 18 years of age or older who has been a patient of CCPRC

  Parents or guardians of patients under the age of 18 who wish to have access to their child's medical records should
  contact our Medical Records Deparment by visiting our Directory Page.

  Already have an Account?

  Click Here to visit the log-in page and sign in.

Please provide the following information to validate your identity based on what CCPRC has on file for you.
*First Name:
*Last Name:
*Date of Birth:
*Social Security Number (last 4 digits only):
Patient Account Number:
*Email Address:
Address Line 1:
Address Line 2:
Zip/Postal Code:
Home Phone (i.e. 2155551234, no dashes):
Mobile Phone (i.e. 2155551234, no dashes):