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.
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.
Myriad Genetics Labratories, Inc.
320 Wakara Way
Salt Lake City, UT 84108
Phone: (800) 469-7423
Fax: (801) 584-3615
Review the fields above to ensure everything is entered and correct.
I understand that:
*If other than the patient’s signature, a copy of legal paperwork verifying the patient’s personal representative MUST accompany the request (i.e. court appointed guardian, durable power of attorney for health care). Exception: parent signing for a patient under the age of 18.
For a deceased patient: A copy of the death certificate identifying the surviving spouse is acceptable and allows the surviving spouse to sign this authorization. Other deceased patients: a court entry or order appointing a fiduciary, executor, or administrator or letters of appointment received from Probate Court must accompany an authorization signed by the named individual. If the estate has not been probated, a death certificate is required coupled with the documents naming the administrator or executor of estate.
By checking I acknowledge I have read all instructions and complete all required information.
To learn more about your rights regarding access to your information please visit: https://www.healthit.gov/access
Myriad Contact Information
Contact Customer Service for questions or help at 1-800-469-7423