Record Request Form
1. Patient Information:
Information is for the person whose records are being
requested. Name, address, date of birth and gender are required.
Phone contact information and Insurance ID number will be
2. Medical Records Requested
Give as much detail as
possible about the records being requested. Indicate
ordering physician name, city
and state as well as month and year the tests were
3. Method of Transmission
If the records are being sent to someone other than you,
please enter the name of the person to receive the records.
The records can be sent
to you in several different ways:
• Please indicate your
preferred way to receive the records.
• Give the appropriate
address for the format you choose.
All requests must be signed and dated. If the
person requesting the records is not the patient, please indicate
what the relationship is between the requestor and the
patient. Legal Guardians and Personal Representatives must
provide written documentation to prove the authority to access the
This form can be taken to an East Side Clinical Laboratory
(ESCL) Patient Service Center. Please provide a valid picture
identification to expedite the process.
Alternatively, the form may be mailed, emailed or faxed to ESCL
along with a copy of two forms of identification (Driver's license
or State Identification card, Insurance card, Military ID, Social
Security card, Passport, US Tribal or Bureau of Indian Affairs ID
card, Certification of Citizenship - N560, Employee Authorization