OBJECTIVE To examine whether chronically ill patients' perceptions of their role relationships with their physicians are associated with levels of patient activation. METHODS Random digit dial survey of 8,140 chronically ill patients and the Area Resource File. METHODS Cross-sectional, multivariate analysis of the relationship between dimensions of patient-physician role relationships and level of patient activation. The study controlled for variables related to patient demographics, socioeconomic status, health status, and market and family context. RESULTS Higher perceived quality of interpersonal exchange with physicians, greater fairness in the treatment process, and more out-of-office contact with physicians were associated with higher levels of patient activation. Treatment goal setting was not significantly associated with patient activation. CONCLUSIONS Patient-physician relationships are an important factor in patients taking a more active role in their health and health care. Efforts to increase activation that focus only on individual patients ignore the important fact that the nature of roles and relationships between provider and patient can shape the behaviors and attitudes of patients in ways that support or discourage patient activation.