Register for the FollowMyHealth™ UofL Physicians Patient Portal

I am requesting access to the FollowMyHealth™ UofL Physicians Patient Portal for *

Self
Minor Child (younger than 18)
Another adult for whom I am the legal guardian. (If you check this box, we will need a copy of the power of attorney; however, you can continue completing registration).
Emancipated minor (Patients younger than 18 who are legally married, living apart from parents, or those who have borne or fathered a child.)

You may send the power of attorney to us in one of three ways: Mail to: FollowMyHealth™ UofL Physicians Patient Portal PO Box 909 Louisville, KY 40201-0909 Fax to: 502-588-0469 Scan and email to patientportal@ulp.org

First Name

Last Name

Please list any other names the patient may have used. (First and Last Name)

Patient’s Date of Birth *

Requestor’s First Name *

Relationship to Patient *

Requestor’s Last Name *

Requestor’s E-mail Address *

Confirm Email

Which UofL Physicians practice did you last visit?

Name of Practice *

Location *

Message

FollowMyHealth™ Registration

Which UofL Physicians practice did you last visit?