Patient Release Form

Filling out the form below gives us permission to share your lab results with you directly.

"*" indicates required fields

PATIENT ACCESS TO MICROGENDX LABORATORY
TEST REPORTS PROVIDED BY CLIA AND HIPAA CHANGES

On February 3, 2014, The US Department of Health and Human Services (HHS) amended the CLIA regulations of 1988 and the HIPAA privacy regulations of 1996 to permit patients and their personal representatives to access laboratory test reports. The new CLIA regulations specify that, upon the request of a patient (or the patient’s personal representative), the laboratories subject to CLIA may provide the patient, the patient’s personal representative, or a person designated by the patient with copies of completed test reports that using the laboratory’s authentication process, can be identified as belonging to that patient.

Patient Information

Please release the laboratory test results for following patient:

Patient First Name*

Patient Last Name*

Last four of patient SSN:*

Patient birth date:*

Designated Representative

Designated Representative Name

Title

Relationship to Patient

Where to Send Results

Please send laboratory test results to:*

Email*

Phone

Fax

Patient Signature

Signature Date*

If you don't receive your results within 5 business days of our receipt of your sample, please call customer service at 1-855-208-0019

PATIENT ACCESS TO MICROGENDX LABORATORY TEST REPORTS PROVIDED BY CLIA AND HIPAA CHANGES

Patient Information

Designated Representative

Where to Send Results

Patient Signature

PATIENT ACCESS TO MICROGENDX LABORATORY
TEST REPORTS PROVIDED BY CLIA AND HIPAA CHANGES