HIPAA Record Release Form
- Authorization. I authorize [PROVIDER_NAME] to disclose the protected health information described below toLabFinder, LLC.
- Effective Period. This authorization for release of information covers the period of healthcare for 90 days from the date of the order for [EXAM_NAME] is requested.
- Extent of Authorization. I authorize the release of my complete health record (excluding records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).
- Purpose. This medical information may be used by LabFinder, LLC and its personnel and affiliates to secure a Prior Authorization for imaging that I book through LabFinder.com, or other purposes as I may direct.
- Duration. This authorization shall be in force and effect until the Prior Authorization is provided by the insurance carrier, or unless revoked by me sooner by e-mailing customerservice@com.
- Right to Revoke. I understand that I have the right to revoke this authorization, in writing, at any time, by e-mailing customerservice@com. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization.
I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.