CONFIDENTIALITY NOTICE: The information contained in the message and accompanying documents are legally privileged and confidential, intended
only for the use of the individual or entity named herein. If you have received this in error, please notify KHEL immediately by calling (785) 296-1620.
Rev. 3/19
REPORT REQUEST FORM
This form is used to request additional copies of final reports.
One Patient Per Form
Facility Name:_______________________________________ Facility ID:________________________
Facility Contact Person (Last, First):_______________________________________________________
Phone Number:_________________________ Secure Fax Number:______________________________
Secure (HIPAA Compliant) Email Account:__________________________________________________
Patient Name (Last, First):________________________________________________________________
Date of Birth (MM/DD/YY):___________________ Collection Date (MM/DD/YY):____________________
Lab ID or Test Request ID (TRID) (Required):______________________________________
The TRID is on the bottom of the submission form with the barcode. The Lab ID is on the final report. If you don’t have either number
you can request them from the submitting facility. If either number is not provided it may take additional time to fulfill request.
MRN (If Applicable):_____________________________________________________________________
Mother’s Name (If Applicable) (Last, First):__________________________________________________
Type of Test Results Requested:__________________________________________________________
Delivery Preference, Check One: Automated Fax Email
I request the above mentioned report to be re-issued and agree to assume responsibility. This document must be signed and
faxed or e-mailed securely to the Kansas Health & Environmental Laboratories (KHEL) before reports issued. Please allow at
least 3 business days for report requests to be completed.
The facility/physician requesting this report is responsible for using these results to treat the patient for which the test was
performed. By signing this request, I hereby attest that I am authorized to receive this test report.
Printed Name (REQUIRED) Signature (REQUIRED) Date
Fax to (785) 559-5205 or Email to KDHE.KHEL_Help@ks.gov
http://www.kdheks.gov/labs/downloads/Report_Request_Form_Fillable.pdf
click to sign
signature
click to edit
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