Instructions for 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 helpful.


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 run.


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.


4. Signature
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 records.

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 card). 

 

Patient Record Request Form