Protected health information (PHI) maintained by my clinical laboratory testing provider or radiology provider consists of test result report(s). In response to this request, I hereby authorize and direct the clinical laboratory or radiology provider identified on the attachment hereto to provide copies of my requested test result report(s) directly to LabFinder, LLC in the manner as directed below.
Pursuant to 45 CFR 164.524 (Access of individuals to protected health information), if an individual’s request for access directs the covered entity to transmit the copy of protected health information directly to a third party designated by the individual, the covered entity must provide the copy to the third party designated by the individual.
Test result report for all tests rendered by the clinical laboratory or radiology provider identified above for the date(s) of service for only those tests scheduled via LabFinder.com or its associated mobile application until this authorization is revoked by me. This authorization will expire when I no longer utilize LabFinder.com or its associated mobile application to schedule testing, and remains in effect for the last test scheduled through LabFinder.com or its associated mobile application.
Indicate Requested Means of Delivery of Records (email or efax), and provide email or efax number:
( Email: Reports@labfinder.com or E-Fax Number: 855-867-6995 )
I understand that my individually identifiable health information is protected from unauthorized disclosure. I hereby authorize the access, use and disclosure of the herein described information for the limited purpose set forth herein. I may receive a copy of this authorization for my records. I understand that I have the right to inspect and copy the information that I have authorized to be disclosed. I understand that I may revoke this authorization at any time in writing, except to the extent that the clinical laboratory, patient service center, radiology provider and/or its sta and/or LabFinder, LLC have taken action in reliance on this authorization. I understand that my patient information, if used for purposes authorized above, may be subject to re-disclosure and may not be subject to any privacy protection. I understand that I may refuse to sign this form and that my health care and the payment for my health care will not be affected if I do not sign this form. To revoke this authorization, e-mail Reports@labfinder.com