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Medical Record Request Form
  Forms must be completed/ submitted prior to leaving our website

Forms must be completed/ submitted prior to leaving our website

Authorization to Disclose Health Information

Authorization to Disclose Health Information

Please have your doctor's fax number available, if possible, as you complete this form. Afterwards, print this form, providing the appropriate signature(s), and return to us in any of the following ways:
  • Fax back to us at 888-204-5975
  • Scan or take a photo of your record and email to us at info@geneticcounselingservices. (privacy issues pertain)
  • Mail to:
    Genetic Counseling Services
    P.O. Box 9205
    Schenectady, New York 12309
  Medical Record Request Form

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.
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)


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. Most likely, you will want to indicate that the information will be used for genetic counseling  for yourself or other.

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 services 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 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 will 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


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 of the individual whose records are requested (unless deceased).

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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