Registration

Portal enrollment is available for Union Health patients who are age 18 or older. Complete the form below to start the enrollment process.

If you manage the health of a patient, talk to the patient's health care provider during the next visit to receive a personal invitation to Union Health. This enrollment form should not be used to request access for caregivers or guardians.

Personal Information

Salutation

Select Mrs. Mr. Ms.

First Name

Last Name

Middle Name

Suffix

Gender

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Date of Birth

Social Security Number

Address

Line1

Line2

ZIP Code

State

Select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marianas Marshall Islands Maryland Massachusetts Michigan Micronesia Military Americas Military Europe/ME/Canada Military Pacific Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

City

Contact

Home Phone Number

Cell Phone Number

Re-enter Cell Phone Number

Email Address

Re-enter Email Address