Karmanos Portal Access Request | Adult | Authorization Representative

Authorized Representative's Information

Authorized Representative First Name: *

Authorized Representative Last Name: *

Authorized Representative Date of Birth: *

Authorized Representative Sex: *

MaleFemale
BothUnknown

Authorized Representative Relationship to You: *

Email Address: *

In order to claim your invitation, you will need to remember your challenge question answer.

Challenge Question: *

Challenge Question Answer: *

I hereby affirm that I am the patient identified above, and I understand that submitting false information might lead to the revocation of my access to Karmanos HealtheLife Portal.

Confirm

Access Request for Adult Authorized Representative

Patient Information

Authorized Representative's Information