HIPAA Record Release Form

  1. Authorization. I authorize [PROVIDER_NAME] to disclose the protected health information described below toLabFinder, LLC.
  2. 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.
  3. 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).
  4. 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.
  5. 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.
  6. 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.

[PATIENT_NAME]
Signature of Patient
[PATIENT_NAME]
Printed Name of Patient
[CREATED_ON]
Requested Date