Portal Access Request | Removal of Authorized Representative

First Name: *

Last Name: *

Date of Birth: *

Sex: *

Male	Female
Both	Unknown

Address Line 1: *

Address Line 2:

City: *

State: *

Zip Code: *

Phone Number: *

Email Address: *

Please Re-Enter Email Address: *

Additional Identifying Information: *

MRN	Date of Service
SSN	I do not have

Patient MRN: *

Patient Date of Services: *

Patient SSN: *

Removal of Authorized Representative From The McLaren HealtheLife Portal