Request for a Change in Medical Records

Change Request Form

Thank you for using MosiacDX. In order for us to maintain accurate medical records, please submit any changes to the original record using this form. Once submitted, we will review the information and get back to you.
Requester's Name (Your name)*

First NameLast Name
I am*

Physician/Physician's OfficePatientPatient's parent/GuardianOther
What is the status of the order?*

The test kit has been shipped to the patient, but the sample has not been shipped back to the laboratory.The patient received the test kit from office, but has not shipped the sample to the laboratory.The sample is in transit to the laboratory.The sample has been received by the laboratory.
Some changes are required to be requested by the ordering Practitioner. We can receive your request, but we may contact your physician to confirm the change.
I would like to make a change to:*

a test or an orderpatient information (sex, Date of Birth, name, weight, address, etc)collection information (date/time of sample collection)physician information (name change, reporting method, contact info, etc)Other
What change would you like to make?*

Add another testCancel an order or testChange the test ordered (Cancel the requested test and add another one)I just want Lab to check if you still have enough sample to run a particular test. Not sure about actually adding a test yet.Other
- Please check our cancellation policy from the link here before submitting this request. https://mosaicdx.com/privacy-and-cancelation-policy/
Which order or test would you like to cancel? *
(i.e.) Mycotox Profile test or order number
Which test would you like to add to the specimen submitted?*
i.e.) IgG food allergy test
Please explain what information you are updating;*
If you are updating date of birth, please make sure to write it in the order of MONTH/DAYS/YEAR or spell out the month.
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Ordering Physician's Name*

First NameLast Name
Email address for this communication*
We will check the email address against the registered email on physician's account. This is also the email we send confirmation and further communication regarding this request.
If outside the cancellation window, you will be billed for the associated cancellation fee.
Name on Card
Card Number
CVV
Expiration Year
Expiration Month
Additional Notes
If any
Please attach any document to add to this patient's record (not required)

Browse Files

Cancelof
By checking the box, I understand that I am officially requesting a change to the test order that I originally submitted. I also understand that changing the test ordered could require additional payment and/or cancellation fee.
Signature*
Should be Empty:

Change Request Form