Myriad Patient Record Request Form
Myriad understands and supports your right as a patient to obtain copies of your medical records. The purpose of this tool is to assist you in generating a records request form which you can print, sign, and submit to Myriad. Please review the following instructions before completing the fields below.
- Not all fields on this form are required; however, submitting this form without enough information to fulfill your request will result in delays.
- Include at a minimum your name and full date of birth.
- Your contact information is essential. This will be used to find your information, verify your identity and locate your records. Complete as much of this section as possible.
- If you think that you may have been tested under a previous or maiden name, please indicate your other previously used name(s) in the field below as this may help in locating your records.
- You have the option to have your records sent directly to you (the patient) and/or to another party.
- Please include as much information as possible in order to ensure your records are being sent correctly. Missing information needed to complete the request will result in delays.
- Under "Recipient Information" there is the option to have all future communication regarding your testing sent to the healthcare provider listed as the recipient. This means that provider will either be added to your record as the designated receiving healthcare provider or that they will replace the previously listed receiving healthcare provider; they will receive all future communications and have access to your test results. This provider will remain on your record until you have requested in writing that they be removed or they are replaced by another provider.
- Whether your records are being sent directly to you, another party, or both, the method of delivery must be selected. If you are requesting information to be sent to yourself and to another party, be sure to identify the delivery method for each, located directly under the "Patient Information" section and the "Recipient Information" section.
- Whichever delivery method is selected, that information has to be listed in the "Recipient Information" section.
Information to be Released:
- Check the applicable box(es) for the information to be released. If you select "Other" a text box will appear below for you to explain/specify what the other records are being requested.