I am requesting access to the FollowMyHealth™ UofL Physicians Patient Portal for *SelfMinor 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 *EmailConfirm EmailWhich UofL Physicians practice did you last visit?Name of Practice *Location *PhoneSubmit