ROI - Medical Record Request Logo
  • Medical Record Request

    Release of information (ROI)
    • parent/guardian/legal representative/authorized 3rd party/other 
    • Parent/guardian/legal representative/authorized 3rd party/other Details

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    • Patient Details 
    • Patient Details

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  • Request records to

  • Genetic Test Request

    Please fill out the form allowing us to share your information with Gene Sight. In the  name section, please put " GenoMind- www.genomind.com, phone number: 877-895-8658." You can then checkmark what we are allowed to share with the company.
  • Release To:

    • Release To Section 
    • MR Section 
    • Medical Records Request

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    • REQUEST OF HEALTHCARE INFORMATION

      I hereby authorize LunaJoy Health Inc and Thriving Lane LLC DBA LunaJoy to release/request medical, psychological, psychiatric, developmental-rehabilitative, alcohol and/or drug abuse, human immunodeficiency virus (HIV) testing and treatment, ARC (AIDS related condition), and/or acquired immunodeficiency syndrome (AIDS) information as it concerns:

  • Forms or Document Completion Request

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    • MR SECTION ONLY 
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  • If you are NOT the patient but are signing on behalf of the patient, please attach proof of your authority to act on behalf of the patient. If proof of authority is not attached, the request will be terminated.

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