Patient Request to Access or to Disclose Laboratory Test Results: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by filling out Section A with your personal information. Ensure you provide your full name, date of birth, and current address. Fields marked with an asterisk (*) are required.
In Section B, specify the test order information. Include the ordering physician's name and approximate dates of service, along with the type of PHI you are requesting.
Proceed to Section C to identify your relationship to the patient. Check the appropriate box and provide your name if you are not the patient.
In Section D, indicate how you would like to receive your PHI. Choose from options such as current address, alternate address, fax, or email. If selecting email, decide between encrypted or unencrypted delivery.
Finally, sign and date the form in Section E before submitting it as instructed at the bottom of the document.

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