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 Medical Record Request Form
Section 1

Section 1

This information is about the individual whose records we are requesting, (name, address,date of birth). For example: if we need your mother’s pathology report, her information goes here. If you are releasing your own records to us, as per our request, then enter your information here, and in the following sections.
Please have the doctor's fax number available, as you complete this form. Note that the doctor who ordered the test/procedure, etc. on which we are now requesting the record, is the doctor whose information and fax number we are requesting.  
1. Today's Date (Month/Day/Year)

1. Today's Date (Month/Day/Year)
2. First Name, M .I.

2. First Name, M .I.
3. Last Name

3. Last Name
4. Address

4. Address
5. Date of Birth (Month/Day/Year)

5. Date of Birth (Month/Day/Year)
Section 2

Section 2

Please fill in the name of the facility and /or doctor, and the address where the records are located under ‘disclosing provider’. Please try to include a fax number.
6. Disclosing Provider or Facility

6. Disclosing Provider or Facility
7. Disclosing Provider Address (if available)

7. Disclosing Provider Address (if available)
8. Disclosing Provider Phone Number (if available)

8. Disclosing Provider Phone Number (if available)
9. Disclosing Provider Fax Number (if available)

9. Disclosing Provider Fax Number (if available)

We can help you with this, if the record is not with your family doctor, oncologist or doctor that you are most familiar with, or if you are uncertain as to who ordered testing. 
Section 3

Section 3

Please fill in with information as to the type of record requested and date of service associated with the medical record that you are requesting. For example: Pathology report from breast biopsy : records for the period June 1, 1995 through June 30, 1995.
10. Record Requested

10. Record Requested
11. Date of Record (Month / Year)

11. Date of Record (Month / Year)
Section 4

Section 4

12. Reason For Request

12. Reason For Request

Please indicate the reason for requesting records. (suggestion: for genetic counseling) 
13. Section 5

13. Section 5

To facilitate the genetic counseling services that you may need and in order to prevent the unauthorized disclosure of your medical records in the future, this medical release is valid for one year.
14. Duration of Medical Release

14. Duration of Medical Release

Please check "I Agree" if you agree to a one year medical release term.  If you wish to specify a different length of time, please check "Other" and indicate the duration of the medical release.

Section 6

Section 6

Please have the appropriate relative (or yourself) sign his/her name, and date as indicated. A (court designated) personal representative for a deceased individual, can sign this form, and should indicate their relationship as requested.
15. Terms and Conditions

15. Terms and Conditions

I understand that my access to genetic counseling service will not be conditional on whether I provide authorization for any requested medical record disclosure. I understand that this authorization is voluntary and that I have the right to refuse to sign it.  I understand that I may inspect or receive a copy of information described in this authorization, upon payment of a reasonable fee.  I understand that I have the right to revoke this authorization in writing at any time by sending written notification. I understand that a revocation will not apply to information that has already been released in response to this authorization.  

I understand that any disclosure to a third person can lead to unauthorized further disclosures by that person or others, and information may no longer be protected by federal privacy regulations and other applicable state or federal laws.  All information released to Genetic Counseling Services or its affiliate, Guide Genetics is guarded with the utmost security and discretion, but to the extent that anonymous information within needs to be reviewed by medical professionals to assist with diagnosis, testing or research options, records may be shared.  

16. First Name, M.I. (of individual organizing this request)

16. First Name, M.I. (of individual organizing this request)
17. Last Name (of individual organizing this request)

17. Last Name (of individual organizing this request)
18. Relationship to person whose medical records are requested

18. Relationship to person whose medical records are requested

Should be self, guardian, parent, power of attorney (please fax any legal documents which may support your authority to 888-2014-5975). 
19. Contact information

19. Contact information

Please provide the address, phone number, and email address of the individual filling out this form.

20. Print, Sign and Fax

20. Print, Sign and Fax

Your signature is required to have on file for the request of medical records.  Please type your name in the box below, print this form and sign your name under your typed name. Fax to us at 1-888-204-5975. This should be signed by the individual who is giving permission for their records to be released to us (unless deceased, death certificate and other documents may be requested).

21. Submit

21. Submit

BEFORE HITTING THE SUBMIT BUTTON, you should print one or two copies of this form.  Please send one signed copy to us, and keep one copy.   This provides a record for future reference if needed. We prefer that you mail (vs. fax) the signed copy, as quality may be lost in faxing.  
22. Verifier

22. Verifier

For security purposes, we ask that you enter the security code that is shown in the graphic. Please enter the code exactly as it is shown in the graphic.
Your Code
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Discussions with a genetic counselor as offered by Genetic Laboratories and Genetic Testing Companies serve to provide key information for the understanding of genetic testing, although pedigree intake and record review may be focused to the results of genetic testing.  Although laboratory license and permit and genetic counselor certification and licensure where applicable, do not permit the practice of medicine, genetic counselors can provide explanation and direction to physicians and authorized medical professionals for the interpretation of the results of genetic testing.  Genetic counselors, upon physician waiver and in collaboration with ordering clinicians, can provide counseling on genetic testing and the meaning of test results. Comprehensive genetic counseling may be available through physicians who can provide genetic counseling within the scope of their practices as they choose and through genetic counselors within the scope of their practice. Please note that patient management and genetic counseling surrounding on-going prenatal or any diagnostic testing is best handled by Physicians, Maternal/Fetal and Pediatric Genetics specialists,  in conjunction with clinical services where they are available and in collaboration with genetic counselors and other genetic specialists. 

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