Patient Record Request

If you do not have the ability to print, stop and call Customer Service at 1-800-469-7423 to order the Record Request form and a postage paid return envelope will be sent to you by mail.

Read Before Continuing

  • The Patient Record Request Tool is to assist you in generating a Record Request form to be printed, signed/dated and sent to Myriad Medical Records by email, fax or mail.
  • Not all fields are required; however, if there is not enough information to locate and verify the person named as patient, or not enough information to fulfill the request, there will be delays.
  • If someone other than the patient will be signing the generated form, a copy of ducmentation appointing this person as the legal representative is required, these documents should be sent in with the completed form:
    • For an Incapacitated Adult: A copy of court appointed guardian, durable power of attorney for health care.
    • For a Deceased Patient: A copy of the death certificate is required. If the Record Request form is being signed by the patient’s surviving spouse then no additional documents are required. Requests by other individuals a copy of the death certificate and secondary paperwork is required, (i.e., will or estate designation documentation).

When filling out the fields, additional instructions for each field will be in italics, anything in Red is required. As you fill the information additional fields may appear if additional information is needed.



Please indicate who will be signing the Record Request form once it has been generated:
Myself, the Patient
The Patient Representative

CHECK THE BOX FOR EACH RECIPIENT PATIENT and/or INDIVIDUAL/HEALTHCARE PROVIDER
You must select at least 1 option, but you can select both. Once a box is checked, additional fields will appear for you to specify what records to send to that recipient and how those records should be sent.

Patient
Select Requested Records:
Test Report
Itemized Billing Statement
Other (please specify)
Method(s) of Delivery:
Mail (to my address listed above)       E-Mail (to my email address listed above)

-AND/OR-

Other Individual/ Healthcare Provider (if selected, populate fields below)
Select Requested Records:
Test Report
Itemized Billing Statement
Other (please specify)
Method(s) of Delivery:
Mail (to the address listed below)       Fax (to the fax number listed below)        E-Mail (to the email address listed below)
Add Healthcare Provider named above to my record. I understand this provider will be added to my record as the designated receiving provider replacing any provider previously listed and they will receive all future communications and test results.

Read Before Continuing- This information will also be on the generated form:

  • If Myriad Genetic Laboratories is unable to confirm my identity based on the information provided in this form and the Company's records, then, in the interest of patient privacy, Myriad will contact me to further confirm my identity before releasing records.
  • Every effort will be made to fulfill my request as soon as possible, but it may take up to 30 days for Myriad to process my request.
  • If I am requesting a copy of my test report, Myriad is required by regulations to wait 14 calendar days after the test has reported before they can send a copy to me directly.
  • If I am requesting records as the patient's authorized representative, I must include a copy of the appropriate legal documentation verifying my authority as the patient's personal representative (e.g., court appointed guardian, durable power of attorney for health care, advanced directive, living will, etc.).

Final Steps

  1. Review the fields above to ensure everything is entered and correct.
  2. I AM READY TO PRINT MY FORM—
    By checking I acknowledge I have read all instructions and complete all required information. I understand I am not submitting my request online, I must print the generated form, sign and date and return to Myriad Medical Records for submission.

To learn more about your rights regarding access to your information please visit: https://www.healthit.gov/access

You must print this form.
Do not send to Myriad Medical Records without being printed, signed and dated.

To submit the completed form you can:

  • Email it to mymedicalrecords@myriad.com
  • Fax it to 801-584-3615
  • Mail it to 320 Wakara Way Salt Lake City, UT 84108 Attn: Medical Records
    • Customer Service can send an envelope with the postage already paid for you to send the form by mail if needed.

Contact Customer Service for questions or help at 1-800-469-7423

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