By submitting this form, I affirm that I am the patient identified above. I understand that I may be subject to penalties under law for submitting false or misleading information in connection with this application to access the My UNC Chart service. I also acknowledge that data transmission over the internet is inherently insecure, and UNC Health Care cannot guarantee the security of my medical records if I choose to download them from My UNC Chart. By downloading my records, I accept all risks associated with the download and agree to indemnify UNC Health Care for any damages resulting from the download.

Created - 06/27/2013 - Revised for ROI Download Terms and Conditions 04/19/2019 - wjk