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1 forms found in the DOM

POST /MyChart/accesscheck.asp

<form autocomplete="off" method="post" action="/MyChart/accesscheck.asp" id="accessForm" onsubmit="return doAccessCheck(0,1,'/MyChart/en-US/Images/warning.png',0,1,'accessErrorMessage','accessForm',9);">
  <div class="formcontents">
    <div class="hidden"><input type="hidden" class="hidden" name="accessformtoken" value="001ECFF1B0A44981889DB19B62F53C84" autocomplete="off"></div>
    <script type="text/javascript">
      var sEmptyFieldErrorAccess = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Please enter your activation code."),
        sInvalidFieldErrorAccess = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Invalid activation code.");
    </script>
    <fieldset class="formsection">
      <legend class="compact header small">MyChart activation code</legend>
      <p class="helptext">Enter your activation code as it appears on your enrollment letter or After Visit Summary®. Your code is not case sensitive.</p><label class="clearlabel inlinelabel" for="code1">Activation Code Part 1</label>
      <div class="segment5"><input class="jsreq" type="text" name="code" id="code1" maxlength="5" value="FX4GN" onblur="isDiscreteFieldsError('code','3','1','codeerror',sEmptyFieldErrorAccess,sInvalidFieldErrorAccess,'',this,'1','');"
          onkeyup="autotab(event,this,document.getElementById('code2'));isDiscreteFieldsError('code','3','1','codeerror',sEmptyFieldErrorAccess,sInvalidFieldErrorAccess,'1',this,'1','');"
          onkeydown="checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'code',1);" onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'-','1');" autocomplete="off">
        <div class="helptext accessibleLabel">xxxxx</div>
      </div><span class="separator">-</span><label class="clearlabel inlinelabel" for="code2">Activation Code Part 2</label>
      <div class="segment5"><input class="jsreq" type="text" name="code" id="code2" maxlength="5" value="3ZK6P" onblur="isDiscreteFieldsError('code','3','1','codeerror',sEmptyFieldErrorAccess,sInvalidFieldErrorAccess,'',this,'1','');"
          onkeyup="autotab(event,this,document.getElementById('code3'));isDiscreteFieldsError('code','3','1','codeerror',sEmptyFieldErrorAccess,sInvalidFieldErrorAccess,'1',this,'1','');"
          onkeydown="checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'code',2);" onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'-','1');" autocomplete="off">
        <div class="helptext accessibleLabel">xxxxx</div>
      </div><span class="separator">-</span><label class="clearlabel inlinelabel" for="code3">Activation Code Part 3</label>
      <div class="segment5"><input class="jsreq" type="text" name="code" id="code3" maxlength="5" value="H6DWZ" onblur="isDiscreteFieldsError('code','3','1','codeerror',sEmptyFieldErrorAccess,sInvalidFieldErrorAccess,'',this,'1','');"
          onkeyup="isDiscreteFieldsError('code','3','1','codeerror',sEmptyFieldErrorAccess,sInvalidFieldErrorAccess,'1',this,'1','');" onkeydown="checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'code',3);"
          onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'-','1');" autocomplete="off">
        <div class="helptext accessibleLabel">xxxxx</div>
      </div>
      <div id="codeerror" class="alert signUpFieldError" aria-live="polite"></div>
    </fieldset>
    <script type="text/javascript">
      var sEmptyFieldErrorDOB = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Please enter your date of birth."),
        sInvalidFieldErrorDOB = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Invalid date of birth.");
    </script>
    <fieldset class="formsection">
      <legend class="compact header small">Date of birth</legend>
      <p class="helptext">Enter your date of birth in the format shown, using 4 digits for the year.</p><label class="clearlabel inlinelabel" for="dob1">Month of birth</label>
      <div class="segment2"><input class="jsreq" type="text" name="dob" id="dob1" maxlength="2" value=""
          onkeyup="autotab(event,this,document.getElementById('dob2')); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'1',this,'1','1');"
          onkeydown="easyDOBEntry(this,1,'',1); checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'dob',1);"
          onblur="easyDOBEntry(this,1); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'',this,'1','1');" onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'/','2');"
          autocomplete="off">
        <div class="helptext accessibleLabel">mm</div>
      </div><span class="separator subtle">/</span><label class="clearlabel inlinelabel" for="dob2">Day of birth</label>
      <div class="segment2"><input class="jsreq" type="text" name="dob" id="dob2" maxlength="2" value=""
          onkeyup="autotab(event,this,document.getElementById('dob3')); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'1',this,'1','1');"
          onkeydown="easyDOBEntry(this,1,'',1); checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'dob',2);"
          onblur="easyDOBEntry(this,1); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'',this,'1','1');" onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'/','2');"
          autocomplete="off">
        <div class="helptext accessibleLabel">dd</div>
      </div><span class="separator subtle">/</span><label class="clearlabel inlinelabel" for="dob3">Year of birth</label>
      <div class="segment4"><input class="jsreq" type="text" name="dob" id="dob3" maxlength="4" value="" onkeyup="isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'1',this,'1','1');"
          onkeydown="easyDOBEntry(this,1,1,1); checkIfTabAllowed(event,this); checkIfFocusOnPrevField(event,this,'dob',3);"
          onblur="easyDOBEntry(this,1,1); isDiscreteFieldsError('dob','3','1','doberror',sEmptyFieldErrorDOB,sInvalidFieldErrorDOB,'',this,'1','1');" onclick="selectIfFull(this);" onkeypress="removeCharFromField(event,this,'/','2');"
          autocomplete="off">
        <div class="helptext accessibleLabel">yyyy</div>
      </div>
      <div id="doberror" class="alert signUpFieldError" aria-live="polite"></div>
    </fieldset>
    <div class="formsection"><label for="zip" class="header small compact">ZIP code</label>
      <p class="helptext">Please enter your ZIP code.</p>
      <script type="text/javascript">
        var sEmptyFieldErrorzip = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Please enter your ZIP code.");
        var sInvalidFieldErrorzip = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Invalid ZIP code.");
      </script>
      <div class="segment5"><input class="jsreq" type="text" name="zip" id="zip" value="" maxlength="10" onkeyup="isBasicInlineValidationError(this,'ziperror',sEmptyFieldErrorzip,'','1','','','','1','',-1);"
          onblur="isBasicInlineValidationError(this,'ziperror',sEmptyFieldErrorzip,'','','','',sInvalidFieldErrorzip,'','',-1);" autocomplete="off">
        <div class="helptext accessibleLabel">xxxxx</div>
      </div>
      <div id="ziperror" class="alert signUpFieldError" aria-live="polite"></div>
    </div>
    <div class="formsection formbuttons"><input class="hidden" type="hidden" id="jsenabled" name="jsenabled" value="0" autocomplete="off"><input class="hidden" type="hidden" name="nfrmhypsp" value="1" autocomplete="off"><input class="hidden"
        type="hidden" name="access" value="Next" autocomplete="off"><input class="button jsreq nextstep" type="submit" name="access" id="access" value="Next" title="" autocomplete="off"></div>
  </div>
</form>

Text Content

PLEASE IDENTIFY YOURSELF





All fields are required.


MyChart activation code

Enter your activation code as it appears on your enrollment letter or After
Visit Summary®. Your code is not case sensitive.

Activation Code Part 1
xxxxx
-Activation Code Part 2
xxxxx
-Activation Code Part 3
xxxxx

Date of birth

Enter your date of birth in the format shown, using 4 digits for the year.

Month of birth
mm
/Day of birth
dd
/Year of birth
yyyy

ZIP code

Please enter your ZIP code.

xxxxx


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