Patient Record Request Form

Myriad understands and supports your right as a patient to obtain copies of your medical records. The Patient Record Request Tool is to assist you in generating and sending a signed pdf Record Request form to Myriad Medical Records. 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 need help filling out the form, call Myriad Customer Service at 1-800-4MYRIAD (469-7423).
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
Previous Name(s) - Indicate any other previously used name(s) in the field below as this may help in locating records
Phone*
Email*
Date of Birth (MM/DD/YYYY)*
MM slash DD slash YYYY
Myriad Patient #
Current Address*
Street Address Address Line 2 City State ZIP Code
Delivery
Preferred Method(s) of Delivery:*
- Email (to my email address listed above)
- Mail (to my address listed above; may take up to 15 days)
Release the Following Information*
- Test Results
- Other (please specify)
Other
Does the patient want a copy of the requested records?*
- Yes
- No
Please mark what type of testing you have if known:
- MyRisk/BRAC/COLARIS & AP/Prolaris/HRD/CDx/EndoPredict
- Prequel/Foresight
- GeneSight
- Other
Other
Preferred Method(s) of Delivery:*
- Email (to my email address listed above)
- Fax
- Mail (to my address listed above; may take up to 15 days)
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*
- Email
- Fax
- Mail (to my address listed above; may take up to 15 days)
Entity or Individual Phone*
Entity or Individual Fax*
Entity or Individual Email*
Optional
- 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. This provider will remain on your record until you have requested in writing that they be removed or they are replaced by another provider. (does not apply to GeneSight orders)
This authorization is to release the protected health information from:
Myriad Genetics Labratories, Inc.
Mail: 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*
- Test Report
Optional
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.
- 180 days from date signed
- On the following date…
- When the following event occurs…
This authorization will expire 180 days from the date signed unless otherwise specified below:
- 180 days from date signed
- On the following date…
- When the following event occurs…
…Date*
MM slash DD slash YYYY
…Event*
Hidden
Disclaimer
I understand that:
- 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 will fulfill my request promptly and let me know of any delays.
- 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.).
- 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

Max. file size: 49 MB.
*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.
Hidden
Today's Date
MM slash DD slash YYYY
Attestation
Attestation*
- I acknowledge I have read all instructions and completed all required information.*
I understand…*
- When using the 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 that you print this form for your records.
- Print form for my records (optional)
Name
This field is for validation purposes and should be left unchanged.

Myriad Contact Information

Mail: 320 Wakara Way Salt Lake City, UT 84108
Phone: 800-469-7423
Fax: 801-584-3615

For questions about your request after it has been submitted, or to check the status of your request, call Myriad Customer Service at 1-800-4MYRIAD (469-7423).

Patient Record Request Form

Authorization to release the protected health information of:

Delivery

This Authorization is to release the protected health information to:

This authorization is to release the protected health information from:

Optional

Disclaimer

I understand that:

Attestation

Myriad Contact Information