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MiCare Facts acts What is MiCare? MiCare is a user-friendly, confidential online healthcare messaging system that allows patients to user dly, ntial ystem nts communicate with their healthcare team, get test results, request prescription refills and maintain cate eir re t s, rescription efills aintain their own personal health record. In the future, information fr ealth . re, tion from your electronic health record ur c ord will be available to transfer directly into your personal health record. ailable ansfer tly ealth . Who can use MiCare? ? MiCare is scheduled for implementation Air Force wide. T f ntation wide That means that once patients have atients e registered they will remain in the system. When PCS-ing, your account will travel with you so you d, emain e sy g, unt el are able to connect with your new clinic at your new duty station. o w our y Is my privacy protected? vacy ed? When using MiCare, a secure connection is established with the browser to validate that your ng nnection stablished wser date ur personal information is encrypted and coded for transmission and storage. This ensures that your d ssion torage. t information and messages are only accessible by you and your healthcare team. In addition, on sages nly e d hcare , MiCare is in compliance with the Health Information Portab ce rmation tability and Accountability Act of 1996 ity 996 (HIPAA). How do I register? Fill out the registration form below and return it to your Medical Treatment Facility (MTF) A MTF e on ow rn eatment ility (MTF). An staff member will verify your identity using your military ID card. Following the in mber ify ntity our lowing n-person submission of your registration, you will receive an emaill asking you to complete the registration on egistration, ive e ation process online. nline. MiCare Registration Form egistration First Name: ___________________________ Last Name: ________________________ e: ____________________ __________ _ : ________________ _______________ ______ Date of Birth (MM/DD/YYYY): ____________________ irth D/YYYY): __________________ ________ Your SSN: _______-_______ _______ ______-________ _____ Home Zip Code: __________________ p _______________ ______ Male Female male

Gender (circle one): G le

E-Mail Address: __________________________________________________________ dress: ______________________________________________________ _____________________________________________ ___________________________________ __________________________ ________________ ________________ ______ Provider/Primary Care Manager: ____________________________________________ Primary e ___________________________________ _________________________ ________________ _______________ ______
This information is subject to the Privacy Act of 1974 (5 U.S.C. Section 552a) s e f C. a)

MiCare Registration Form egistration January 30, 2012

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Patient ID Verified: D

Date: __________ : __

taff Initials: _______________ f ______________ ____

-mail Invitation ent: vitation t:

Date: __________ _

taff Initials: _______________ f _____________ ____

MiCare Registration Form egistration January 30, 2012