Fillable Patient Request to Access or to Disclose Protected

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Patient Request to Access or to Disclose Protected

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Patient Access Form Privacy 703A-F1 (Lab) January 2021
Patient Request to Access or to Disclose Protected Health Information (PHI) (Access Form)
You may use this Access Form to submit a written request to obtain PHI from Diagnostic Laboratory of Oklahoma (DLO) or to
have us share PHI on your behalf. Information marked with an asterisk (*) is required. We will respond to your request within
thirty (30) days of our receipt of this Access Form.
N
OTE: For fast and easy electronic access to your lab results, you may visit www.questdiagnostics.com/MyQuest
or
download the MyQuest App for iPhone or Android.
A. Patient’s Information
N
ame*: ________________________________________________________________________________________
First Name Middle Name/Initial Last Name
N
ame at time of service if different than above, nickname(s) or alternate spellings*:_____________________________
_______________________________________________________________________________________________
Date of Birth*: __________________________________________ Phone Number: ( )_____________________
_______________________(MM/DD/YYYY)
Cur
rent Address*
____________________________________________________________________________________________________
A
ddress at time of service if different than above:*
____________________________________________________________________________________________________
Las
t Four Digits of Social Security Number:____________ Insurance ID#:______________________________________
B
. Test Order Information
R
equested PHI*: Laboratory Test Results Order Form Other—please specify:______________________________
____________________________________________________________________________________________________
C
. Identification—Check one of the following as applicable*:
I am the patient named above
I am the parent of the patient named above
I am the legal guardian of patient of the patient named above (provide proof such as court order or power of attorney)
I am the authorized representative of the patient named above (provide proof such as court order, healthcare proxy, power
of attorney)
If not the patient, print your name clearly: __________________________________________________________________
First Name Middle Name/Initial Last Name
Ordering Physician/Office Name
Address
Phone
Approximate Dates of Service
~
Patient Access Form Privacy 703A-F1 (Lab) January 2021
Patient Access Form—Page 2 of 2
D. Delivery Instructions—check all that apply and print clearly*
I request that the PHI described in this Access Form be provided to me (the patient) or the person(s) named below:
□ Me (the patient) at CURRENT address in Section A above
□ Me at this alternate address:_________________________________________________________________
____________________________________________________________________________________________
□ Me at fax number: ( ) _____________________________
□ Me by email—please read this important caution and select one:
Our standard practice is to send encrypted (secure) email, which means you will be prompted to create a free account or log in
to access the message. This would be a separate account/login from any MyQuest account you may have. If you prefer, we
will send you unencrypted email, but this way of communicating carries some risk that PHI in the email can be viewed or
accessed by unauthorized parties.
□ Encrypted email (recommended)
□ Unencrypted email—I have read and understand the caution above and accept the additional privacy risk.
Email address (if email delivery is requested):______________________________________________________
□ Person(s) named below:
Name: ___________________________________________________________________________________________
Address, fax number or email address: _________________________________________________________________
________________________________________________________________________________________________
Name: ___________________________________________________________________________________________
Address, fax number or email address: _________________________________________________________________
________________________________________________________________________________________________
E. Signature*_______________________________________________ Date*: ____________________________
F. Please submit this completed Access Form (and any proof of representation, if required) to:
Diagnostic Laboratory of Oklahoma Or fax to: 405-608-6230
Attn: Client Services
225 NE 97
th
Street Or email to: DLOCSC@questdiagnostics.com
Oklahoma City, OK 73114
For office use only: Tracking #:_________________
Initials: _______
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Patient Request to Access or to Disclose Protected

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Completed 11 March 2022

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