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Bacon County Hospital

Portal Enrollment Request

If not previously enrolled or if you're having issues with self-enrollment, please use this form to request enrollment.

This form is only to be used when requesting access to your own health records. A parental proxy access request form must be completed in person first to gain access to a minor's health records.


* First Name
* Last Name
  Middle Initial
* Telephone
Enter phone number with area code (ie 555-555-5555)
* Email
Please enter email address you would like to enroll with
* Birth Month
* Birth Day
* Last 4 digits of your social security number