Authorization Form For Release Of Test Results printable pdf download

Compliance and Regulatory Information

Section 2

Authorization Form for Release of Test Results

to the Patient by the Laboratory

IU HEALTH PATHOLOGY LABORATORY

Indianapolis, IN 46202

Indiana University Health Pathology Laboratory (IUHPL) will make a limited number of results available directly

to the patient (or their designated representative) upon physician’s written request for direct release of results to the

patient.

1. Direct release of test results to patients will be limited to specific test results that are necessary for the patient’s

use to provide timely care and treatment. These tests are:

AFP Tumor

PTINR

aPTT

Glucose

HgbA1C

PSA

Marker

Tacrolimus

Platelet

Cyclosporine

WBC

Hgb

Hct

(FK506)

Count

Strep

Rapid

Sed rate

RSV

MonoSpot

Screen

Flu Test

2. All other test results may be obtained from the ordering physician, or through Indiana University Health, Health

Information Management/Medical Records M-F between the hours of 8 AM-430 PM. Methodist: (317) 962-

8911/Room (DG 402) or UH/Riley: (317) 994-2337/ Room (UH 3280).

3. This service is available only for testing performed in one of the IUHPL’s labs.

4. IUHPL requires the patient to obtain their results by telephone (results will not be made available at the

collection site).

•

Each patient will be requested to provide certain required identification information at the time of their

telephone inquiry; the minimum information requested will be - full name, name of the test, date collected,

ordering physician and the patient’s unique 4 digit lab - PIN code.

•

Patients will be asked to write down the results and to repeat the results reported to them.

•

Results will be available by phone ONLY. Contact (317) 491-6000.

•

For Standing Orders - Patients will be asked to bring a copy of this signed release with them each time

that they present themselves for testing.

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

confidentiality of the PIN code and test results once they are provided by IUHPL.

Inherent Risks:

•

Result(s) recording errors by the patient

•

Inappropriate interpretation and / or action by the patient

PATIENT AUTHORIZATION AND ACCEPTANCE OF RELEASE PROCESS:

Date ___________________ Signature _______________________________________

Patient

Signature _______________________________________

Parent / Guardian

Modified January 2011

Authorization Form For Release Of Test Results

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