Medical Records Request

Medical Records Request

According to HIPAA Regulations, Mosaic Diagnostics has up to 15 days to process Medical Records requests. Once processed, please allow additional time for mailing if a physical copy is requested.
I request and authorize Mosaic Diagnostics to disclose the protected health information indicated below to the recipient indicated below.

This protected health information is disclosed at my request in compliance with 45 CFR 164.508(c)(1)(iv).

I acknowledge that I have the right to revoke this authorization, in writing, by sending written notification to Mosaic Diagnostics. However, I understand that any actions already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

I acknowledge the potential for information disclosed pursuant to this authorization to be subject to redisclosure by the recipient and no longer be protected under HIPAA privacy rules.

I understand that Mosaic Diagnostics may not condition treatment, payment, enrollment or eligibility for benefits on whether or not I sign the authorization.

Any facsimile, copy or photocopy of the authorization shall authorize Mosaic Diagnostics to release the records herein.
Do you agree to the above conditions?*

YesNo
Does the Patient reside in the United States or Canada?

YesNo
Requester's Name (your name)*

First NameLast Name
Email address for additional communication*
example@example.com
I am*

Physician/Physician's OfficePatientPatient's Parent/GuardianOther
I would like to request*

Test ResultsItemized ReceiptReceived Test Requisition Form
I would like*

The most recent test resultsTest results over a date range
Results from*

MonthDayYear
MM-DD-YYYY
Results to*

MonthDayYear
MM-DD-YYYY
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
MM-DD-YYY
Patient's Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Under California law, medical records are the property of the ordering provider. The Health and Safety Code section 123148 of California requires that the health care professional who requested the test to provide a copy of the results to the patient. Per California law, the laboratory cannot provide results directly to the patient.

Please follow up with the ordering provider to obtain a copy of the requested results/medical record.
Ordering Physician's Name*

First NameLast Name
I would like to receive records by*

Mail (Paper copy sent via postal service.)Email: Encrypted (Password-protected email which requires a 2-step process. Email includes instructions on accessing.)Email: Un-Encrypted (Unsecured, emailed copy of results.)Fax
Please enter the email address that you would like records sent to*
example@example.com
Please enter the address you would like the records to be mailed to*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please enter your fax number*
Additional Notes
If needed
Supporting Documents

If needed
Cancelof
Signature

Clear
To complete this request, you must agree to the conditions at the top of the form.
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