Name: | DOB: | MRN: | PCP: | Legal Name:

Request Access to your myACPNY Patient Portal Account

We need some information from you in order to grant you a myACPNY account. Once submitted, it could take up to 3 business days for processing and verification. Once approved, you will receive an email or a letter with your activation code and instructions on how to activate your myACPNY account. If you have any questions, please contact your medical office.

Please note that due to state regulations, users under the age of thirteen cannot create a myACPNY account. Please have a parent or guardian request proxy access through their myACPNY account, or by filling out this form with their own information and then requesting proxy access from that account once created.