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.
