Request For Access To Protected Health Information - Greenwood Genetic Center
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1Request For Access to Protected Health Information
Date of Request: __________________
The person requesting this information is:
A healthcare provider
The patient
Family member
Other: _______________________________
Name of person/institution requesting PHI: _________________________________________________
Address of person requesting PHI: _________________________________________________________
Phone number of person requesting PHI: ___________________________________________________
Fax number of person requesting PHI: ______________________________________________________
Patient Name: ________________________________________________________________________
Date of Birth (MM/DD/YYYY):____________________________________________________________
I authorize the Greenwood Genetic Center’s Diagnostic Laboratories to release the following potentially
sensitive information:
Laboratory Reports
Consultations
Other: ______________________________________
The purpose of the disclosure is
Continuation of Care
Legal
Insurance
Patient Request
Other______________
------------------------------------------------------------------------------------------------------------------------------------------
This section should be filled out if this is a patient or a non-healthcare provider request.
(Healthcare providers requesting records as part of continuation of care do not need to complete this section.)
Please notify me when the information is ready to be picked up at___________________________
Please send the copies of the records to above address.
Please send the copies of my record to me at the following address__________________________
____________________________________________________________________________________
This authorization remains in effect for one year. I understand that I have a right to cancel or revoke this
authorization at any time by contacting the GGC Diagnostic Laboratories in writing at the address below.
I understand that authorizing the disclosure of protected health information is voluntary. Information
used or disclosed in response to this authorization may be subject to redisclosure by the recipient and may
no longer be protected by the Greenwood Genetic Center’s Privacy Policies.
Signature of Patient or Representative ____________________________Date ____________________
Relationship to patient (if representative) __________________________________________________
*A copy of the patient’s identification must be attached to this authorization.
Send completed form to:
The Greenwood Genetic Center Diagnostic Lab
106 Gregor Mendel Circle
Greenwood, SC 29646
Fax Number: (864) 941-8141
Contact us with questions at 1-800-473-9411
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