MyChart -

As of spring 2023, participants in all of InnovAge's Pennsylvania and Virginia centers can enroll in MyChart. Participants at other locations will be contacted as MyChart rolls out to all centers.

To request proxy access, please complete the form below. We will contact you by phone or email if we have any questions regarding the information provided.

Step 1 | TELL US ABOUT YOU

Today's Date:

First Name:

Middle Initial:

Last Name:

Your Date of Birth:

Your Social Security Number:

Street Address:

City:

State:

Zip Code

Mobile Phone (xxx-xxx-xxxx):

Email Address:

Step 2 | PARTICIPANT INFORMATION:

Participant's First Name:

Participant's Middle Initial:

Participant's Last Name:

Participant's Date of Birth:

InnovAge Center

Your relationship to the Participant:

If other, please specify:

SECOND PARTICIPANT INFORMATION:

Participant's First Name:

Participant's Middle Initial:

Participant's Last Name:

Participant's Date of Birth:

InnovAge Center

Your relationship to the Participant:

If other, please specify:

THIRD PARTICIPANT INFORMATION:

Participant's First Name:

Participant's Middle Initial:

Participant's Last Name:

Participant's Date of Birth:

InnovAge Center

Your relationship to the Participant:

If other, please specify:

"YES, I sign this form electronically and certify that all information I have provided is correct. By signing this form, I acknowledge that I have read, understand, and agree to abide by the Terms and Conditions of Use posted on the MyChart website. I understand that a violation of such terms may result in loss of access to MyChart."

MyChart Activation Request: New Proxy Account

Step 1 | TELL US ABOUT YOU

Step 2 | PARTICIPANT INFORMATION:

SECOND PARTICIPANT INFORMATION:

THIRD PARTICIPANT INFORMATION: