Name: | DOB: | MRN: | PCP:

Request to Access a patient's Record

Enter information about the patient to whom you are requesting access. All fields are required.

Patient:

Additional information:

If you are requesting proxy access, otherwise known as access on another’s behalf, for a legal ward, stepchild, sibling, spouse, parent, or someone else, please email Power of Attorney or Legal Guardianship Documentation to ClinicalLabQA@exactsciences.com. In your documentation please include patient date of birth, first/last name, and in addition address or phone number if possible. If you are requesting proxy access for a child, then no additional documentation is needed.

Your proxy access request will be reviewed within 3 business days. Exact Sciences Laboratories will contact you if additional information is needed.