Genetic Testing Records Release Form
Patient Information
Full Name
Date of Birth
Address
Phone Number
Email
Recipient Information
Name of Recipient/Organization
Address
Phone Number
Fax/Email
Information to be Released
Specify Records to Release
Purpose of Disclosure
(Specify if only certain tests, date ranges, or information should be disclosed.)
Authorization
I authorize the release of my genetic test results and related health information as specified above.
Patient Signature
Date
If signed by Legal Representative, Name
Relationship
This release is valid for one year unless otherwise revoked in writing.