Authorization Form For Release Of Test Results To The Patient By The Laboratory printable pdf download

Authorization Form For Release Of Test Results To The Patient By The Laboratory

™

15000 W 6

A ve, S te 1 50

Golden, C O 8 0401

(844) 2 13-‐2329

Authorization Form for Release of Test Results

to the Patient by the Laboratory

Baby Genes Laboratory will release results directly to the patient (or designated representative) only upon written and signed

request by the ordering physician.

Patient Name

Patient DOB

Patient ID

Testing Order

Ordering Provider Name

Provider NPI

Phone

Fax

1. This service is available only for tests performed at a Baby Genes Laboratory.

2. The patient and/or a designated representative will be fully responsible for maintaining the integrity and

confidentiality of test results once they are provided by the Baby Genes Laboratory.

3. Inherent Risks:

a. Inappropriate interpretation and/or action by the patient

b. Result(s) recording errors by the patient

By signing below, I ____________________________________, the ordering provider, understand and accept the terms and

risks listed above. Upon the return of this signed form, test results will be released directly to the patient by the

preferred method listed below.

____________________________________________________________

________________________

Ordering Physician Signature

Date

Please release results to the patient via the following delivery method:

Address/Number

q

Mail

q

Fax

(Internal Use Only)

Date of Authorization Receipt_______________

Baby Genes Representative_________________________________

Date of Results Release __________________

Baby Genes Representative Initials __________________

Authorization Form For Release Of Test Results To The Patient By The Laboratory