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Consent NOTE: To sign-up for MyChart, you are required to answer a short series of questions. The answers you provide will authenticate that "you are who you say you are". We utilize a 3rd-Party Service to provide these security questions based upon publicly available information and the service provider's databases. We provide your information to the service provider to enable them to generate these security questions. Neither the questions nor answers are retained or stored by Bon Secours Health Systems. Bon Secours Health Systems and its controlled affiliate physician practices Virginia. ("Bon Secours Health Systems") provides a secure web site known as MyChart to allow you to access some (but not all) of your confidential health information contained in your Bon Secours Health Systems electronic medical record ("EMR"), to the extent you have a Bon Secours Health Systems EMR. MyChart is not your complete EMR. In addition, MyChart sometimes shows a summary or description and not the actual entries in your EMR. You can access MyChart by logging into the web site mychart.mybonsecours.com with a special identification code. In order to obtain the identification code, you must complete this IDENTIFICATION VERIFICATION FOR ACCESS TO MYCHART REQUEST, and must accept and agree to comply with the MYCHART ACCESS RESPONSIBILITIES set forth below. When you first activate your MyChart account, you will also be required to read and agreed to comply with the MYCHART TERMS AND CONDITIONS OF PATIENT USE. I hereby acknowledge that the above information, including my name, e-mail address, date of birth, Social Security Number, and mailing address is true and correct.

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