Patient Request To Access Or To Disclose - Quest Diagnostics printable pdf download

Patient Request to Access or to Disclose Protected Health Information (PHI)

In order for us to identify the requested patient PHI, please complete all required information. Using the information provided, we will attempt to identify the

laboratory tests results and or order form. *Indicates REQUIRED information.

A. Patient’s Information:

Name*: ___________________________________________________________________________ Phone Number: (_____) ____________________

First Name

Middle Name/Initial

Last Name

All other Names*: (nicknames, alternate spellings, former name, etc.):________________________________________________________________

Date of Birth*: ___________________________________________

(MM/DD/YYYY)

Address*: __________________________________________________________________________________________________________________

Social Security Number (last four digits)______________________________

Insurance ID# ____________________________________________

B. Test Order Information:

Ordering Physicians’ (or Office) Name(s)*: _____________________________________________________________________________

______________________________________________________________________________

Ordering Physician’s Address(s)*:

Approximate Date(s) of Service*: (MM/DD/YY)

________________________________________________________

_________________________

___________________________

________________________________________________________

_________________________

___________________________

Phone Number(s): (_____)___________________________________

(______)________________________________________________

 Laboratory Test Results

 Order Form

 Other:__________________________________________

Requested PHI:

C. Requester Authorization:

By my signature, I request that Quest Diagnostics search its records and provide me or the individual I request in box D below, with a copy of the PHI

requested.

NOTE: If you are a legal representative of the patient please provide proof of representation as requested (healthcare proxy, court order, power of attorney,

etc.).

Printed Name*: ______________________________________________

*Relationship: (Check One)

⁭

 Self

 Parent

 Legal Guardian

 Legal Representative

(Provide Proof)

Signature*: __________________________________________________

Date*: _____________________

For easy electronic access to your lab results, please