Data Request Authorization

SAMPLE DATA REQUEST LETTER

DNA Diagnostics, Inc.
2121 Main Street
Albuquerque, NM 88322

Re: HIPAA Request for Access to Personal Health Information Related to:
Report #: 1234512345
Patient Name: Melinda Johnson

Attn: Gerald Carter
Medical Director
[email protected]

Dear Dr. Carter,
Your laboratory performed a molecular diagnostic test for me at the request of my physician. The test was performed on August 9, 2016 and the report number was 1234512345.

Pursuant to the HIPAA Privacy Rule, I am writing to request an electronic copy of the findings of my test, including all the variant information generated by the test you performed for me. In particular, I am requesting the DNA sequence variants, in a structured data file format, such as a variant call file (.vcf).

I request and authorize you to disclose and transmit the requested data to Cure Forward, an online precision medicine platform where I can access and use my molecular test data to become conversant in my disease, participate in a community, and find treatment options. I have authorized Cure Forward to receive this data on my behalf. To learn more about Cure Forward, please visit www.cureforward.com.

Cure Forward will provide delivery instructions in an email accompanying this request.

For additional information about a patient’s right to access genetic information, and the right to designate third parties as recipients of that information under the HIPAA Privacy Rule, please consult the detailed guidance on this topic that is available from the Office for Civil Rights, United States Department of Health and Human Services at: http://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/

Please respond to this request as soon as possible. If this request, or any part of it, is denied please promptly notify me in writing of the reasons.

Sincerely,

Melinda Johnson


Signature of Patient of Authorized Representative

August 29,2016
eSignature Date

My birth date: 03/19/1962

You can reach me at: [email protected]

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