Instructions for Record Request Form
1. Patient Information:
Information is for the person for whom 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:
Check the first box for results of lab tests collected or dropped off today.
If older records are requested give as much detail as possible about the records. 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 contact information for the format you choose.
4. Patient Portal:
Each patient has the right to access their laboratory records with both security and confidentiality. The CPL
Patient Portal is a standardized tool for patients to view their laboratory reports at their convenience. The
portal matches your request for the current report to any prior results currently in the laboratory’s computer
based on an algorithm using your name, date of birth, insurance information and additional demographic
information.
A personal email address is required for registration
Laboratory reports will be available via the patient portal after the 72 hour hold
The last 2 years of historical laboratory reports will be available
Future laboratory reports will be available without further re-registration, barring any issues
All patient demographics must match laboratory reports in order to be viewed in the patient portal.
While the portal program is designed to link prior and subsequent laboratory results, if there are
issues with the order or demographic information, those results may not be automatically linked.
Please review your records and call the laboratory if you feel that there are results that cannot be
retrieved.
5. 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. Parents or legal guardians may
obtain and/or authorize the release of protected health information from their child's medical record if the
child is 17 years old or younger. Individuals over the age of 17 must authorize the release of their own
information.
Legal Guardians and Personal
Representatives must provide written documentation to prove the authority
to access the records.
This form can be left at the Clinical Pathology Laboratories (CPL) Patient Service Center. Please provide a
valid picture identification to expedite the process.
Alternatively, the form may be mailed, emailed or faxed to CPL 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). See bottom of form for submission information.
RECORD REQUEST FORM
(instructions on reverse)
*Name - Last *First MI
Other names to search (maiden name, nicknames, forme
r
names, etc)
*Address
Insurance I.D. Cell Phone or Other Primar
y
Phone
*Date of Birth (MMDDYYYY) *Sex
M M D D Y Y Y Y
82480
Patient Record
Request
9200 Wall Street
Austin, TX 78754
A
ccession
Internal Use Onl
y
Photo ID Verified
PSC ID
RR 2
810 Pt Record Request for current accession
(place accession label above)
817 Standing/Future Order
Rev 11/2016
Phleb ID
815 Pt Record Request for past records
2. PLEASE INDICATE THE MEDICAL RECORDS REQUESTED:
Results for the laboratory tests collected or dropped off today
(810)
Prior results specified below
(815)
Ordering Physician Name Ordering Physician City & State Date of Service Month & Year
Other records, specify records requested and approximate date of service
(815)
3. PLEASE SELECT ONE OF THE FOLLOWING METHODS FOR TRANSMISSION:
Send to (enter Name if different from above):
*By (please mark one):
Email address:
Fax Number:
Mail (enter address if different from above):
4.
REGISTER FOR CPL PATIENT PORTAL:
Email address: _____________________________________________________________________________________________
My signature below authorizes Clinical Pathology Laboratories (CPL) to release the records containing Protected Healthcare Information
(PHI) I have requested.
5.
*
Signature:
*Date:
*Printed Name:
*Relationship:
Self
Parent
*Initials:
LegalGuardian
Personal Representative
FOR INFORMATION OR TO SUBMIT FORM:
(provide proof) (provide proof)
Clinical Pathology Laboratories phone: (844) 280-8484 (toll free) Visit: www.cpllabs.com
PO Box 144193 fax: (844) 456-2264
Austin, TX 78714-4193 email: patientrecords@cpllabs.com
CPL will use best efforts to respond within 2 weeks of request unless testing requires extended period of time.
For patient safety, any changes to information require a new form to be completed.
*Indicates REQUIRED Information
Patient Verification
of Information
Initials
Date
For
each use with 817
Submit Request
click to sign
signature
click to edit
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