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: *

Male	Female
Both	Unknown

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

MRN	Date of Service
SSN	I do not have

Last four of your SSN	Year you got married
Year you graduated high school	Year your father graduated high school
Year your father was born	Year your mother graduated high school
Year your mother was born	Your postal code

Access Request for Adult Authorized Representative

Patient Information

Authorized Representative's Information