Fillable MRR and Authorization-to-Release Form (WestPac Labs)

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MRR and Authorization-to-Release Form (WestPac Labs)

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The MRR and Authorization-to-Release Form (WestPac Labs) form is 2 pages long and contains:

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  • 6 check-boxes
  • 37 other fields

Country of origin: US
File type: PDF

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Information for patients
MRR and Authorization-to-Release Form
Download and complete the Region, Personal Information, and Delivery Instructions sections of the Medical
Records Request and Authorization-to-Release form. Ensure this form is signed and dated.
NOTE: Authorized representatives of patients must provide supporting documentation to that effect, i.e. Patient Authorization, copies of Power of
Attorney, Certificate of Conservatorship, or another official legal document.
Delivery Instructions:
If the r ecords are being sent to someone other than you, please enter the name of the person to
receive the records.
The records can be sent in different ways:
Mail, Email and Fax
Please indicate the preferred way to send records
Please pr ovide the appropriate and accurate contact information for the
format that you chose.
Submit:
In person by pr esenting the request form, copy of a valid photo ID and, if applicable, supporting
documentation to any WestPac Labs location.
Via email t o the email address for your region as listed on the form. Remember to include a copy of
a valid photo identification and, if applicable, supporting documentation.
Via fax, A ttn: Client Service Department to the fax number for your region as listed on the
form. Remember to include a copy of a valid photo identification and, if applicable,
supporting documentation.
Please note that while most requests are processed immediately upon receipt, California State law allows the laboratory 15 days in which to fulfill
each request. In some cases, requests may require additional processing time in addition to the 15 days. If this occurs, you will be notified.
Advice to Patients Receiving Clinical Laboratory Results
Appropriate medical expertise is required for the correct interpretation of clinical laboratory results and is not
available from laboratory personnel. Caution is urged in regard to individual interpretation of these clinical
laboratory results.
Please consult your physician. Under no circumstances should any action be taken based on these values
without first discussing them with your physician/practitioner.
PLACE BARCODE HERE
MRR and Authorization-to-Release Form
Region
Bakersfield (PAL Patients)
Fax: 661.327.9163
Email: PatientRecords_BAK@westpaclab.com
California (WPL Patients)
Fax: 562.906.6490
Email: PatientRecords_SFS@westpaclab.com
San Luis Obispo (CCPL Patients)
Fax: 661.327.9163
Email: PatientRecords_SLO@westpaclab.com
Personal Information
Patient First Name:
Staff Use Only
Photo ID Verification
Date of Birth: Phone Number:
Date(s) of Service: Ordering Physician(s):
Comments:
Send to (Enter name of person(s) if different from patient name above):
Delivery Instructions
Mail Address:
Email Address:
Fax Number:
Patient Portal (Personal Account)
Patient Portal (Guardian Account)
Please note that while most requests are processed immediately upon receipt, California State law allows the laboratory 15 days in which to fulfill each request.
In some cases, requests may require additional processing time in addition to the 15 days. If this occurs, you will be notified.
Consent
I hereby request WestPac Labs to release copies of my laboratory results.
Signature of Patient or Legal Guardian (if minor): Date:
Signature of Personal Representative
*
:
Relationship to Patient: Date:
* Must be accompanied by supporting documentation (for example, letter from the patient, Power of Attorney, Certificate of Conservatorship, or another
official legal document).
State law does not permit access to a minor’s sensitive lab results (for example, tests pertaining to pregnancy, HIV or other STIs [sexually
transmitted infections] without authorization).
Episode Information (staff use only)
Episode Number(s):
(If additional space is required, attach list)
Request Received By:
(Employee Name or ID)
Date: Dept or PSC:
1
st
Reply Sent: / / Initials: 2
nd
Reply Sent: / / Initials:
No Response, Sent to Imaging: / / Initials:
Results provided to patient and/or personal representative?
YES NO
WestPac Labs | 10200 Pioneer Boulevard, Suite 500, Santa Fe Springs, CA 90670 | www.westpaclab.com | P: 562.906.5227
Copyright © 2022 Sonic Healthcare USA, Inc. All rights reserved. All of the information in this document is the property of Sonic Healthcare USA. It may not be distributed, transmitted, reproduced, copied or displayed
without the written permission of Sonic Healthcare USA. Sonic Healthcare USA, including its affiliates, does not dispense medical advice. The content in this marketing collateral is intended for informational purposes
only and does not constitute legal, medical or any professional advice. Please consult your physician or a healthcare provider for additional information.
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MRR and Authorization-to-Release Form (WestPac Labs)

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Completed 6 July 2022

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