Consent to Release Laboratory Test Results
Patient Name
Date of Birth
Recipient Name/Organization
Recipient Address / Email / Fax
Specific Laboratory Test Results to be Released
I hereby authorize the release of my laboratory test results as specified above to the indicated recipient.
This authorization is valid for this instance only.
This authorization is valid until revoked in writing.
Patient/Legal Representative Signature
Date
If signed by legal representative, specify relationship to patient