Vectra Patient Record Request Form

Patient Request Form:

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 you're requesting your own records, you understand

Crescendo Biosciences, Inc. (“Myriad”) is a subsidiary of Myriad Genetics, Inc.
If Myriad 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 certain regulations to wait 8 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.).
If someone other than the patient will be signing the generated form, a copy of documentation 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.

If you have any questions or problems please call Customer Service at 1-877-743-8639.

Who am I requesting records for?*

Myself
My HealthCare Provider
Both

Authorization to release the protected health information of:

Name*

Patient First Name Patient Last Name

Date of Birth (MM/DD/YYYY)*

MGL#

Last 4 digits of your Social Security #

Previous Name(s) - Indicate any other previously used name(s) in the field below as this may help in locating records

Current Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Delivery

Preferred Method(s) of Delivery:*

E-Mail (to my email address listed above)
Mail (to my address listed above)

Release the Following Information*

Most Current Result
All Results
Billing Records
Other (please specify)

Other

Does the patient want a copy of the requested records?*

Yes
No

Preferred Method(s) of Delivery:*

Mail (to my address listed above)
E-Mail (to my email address listed above)
Fax

Fax*

This Authorization is to release the protected health information to:

Name of Entity or Individual (e.g., name of healthcare provider)*

Address of Entity or Individual*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Entity or Individual Delivery Method*

Mail (to the address listed above)
Fax
E-Mail

Add Healthcare Provider named above to my record.

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.

Entity or Individual Phone*

Entity or Individual Fax*

Entity or Individual Email*

This authorization is to release the protected health information from:

Myriad Genetics Labratories, Inc.
320 Wakara Way
Salt Lake City, UT 84108
Phone: (800) 469-7423
Fax: (801) 584-3615

The purpose of this use or disclosure is:*

At the request of the individual

Release the Following Information*

Most Current Result
All Results
Billing Records
Other (please specify)

Other

This authorization will expire 180 days from the date signed unless otherwise specified below (requests to add a healthcare provider to my record do not expire unless this authorization is revoked):

On the following date…
When the following event occurs…

…Date*

…Event*

Disclaimer

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 certain regulations to wait 8 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

Review the fields above to ensure everything is entered and correct.

I understand that:

Myriad Genetic Laboratories relies heavily on information provided by ordering physicians at the time that laboratory tests are ordered. The information provided by my ordering physician may not be sufficient to reasonably match the information I provide on this form. In the event that Myriad is not able to reasonably match such information according to their strict criteria, they will protect patient privacy by NOT releasing the requested information.
information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule.
this authorization will remain in effect until the authorization expires or I provide a written notice of revocation to Myriad’s Privacy Office at the address listed above. If I revoke this authorization, Myriad may not be able to reverse the use and disclosure of the health information while the authorization was in effect.
Myriad will not condition treatment, payment, enrollment or eligibility for benefits on whether or not I sign this authorization.

Please indicate who will be signing the Record Request form:*

Myself, the Patient
Patient Personal Representative*

Personal Representative Name*

(Please attach applicable legal documentation*)

Relationship to Patient*

Legal Documentation Upload (optional)

Drop files here or

*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.

Signature*

Using your mouse (or your finger on mobile devices), please sign to verify your request to release records.

Today's Date

I understand…*

When using the Vectra Patient Record Request tool, we send you an email with a copy of your request for records. The email is sent unsecure. This means a third party may be able to access the information and read it since it is transmitted over the internet. I understand the risks of unsecure email and do hereby give permission to Myriad Genetics Laboratories to send me a copy of my records request that contains protected health information via email.

We recommend you print this form for your records.

Myriad Contact Information

Email: mymedicalrecords@myriad.com
Fax: 877-743-8640
Mail: 320 Wakara Way Salt Lake City, UT 84108 Attn: Medical Records

Contact Customer Service for questions or help at 1-877-743-8639