TruChoice Diagnostics Self-Pay Lab Work DRAFT (as of 8.8.2023)

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

To receive a copy of your results please review and sign below:
1. I understand that this authorization will expire 1 year from the signature date
2. I understand that I may revoke this authorization prior to the release of results.
3. I understand that I can refuse to sign this authorization and my service or care will not be affected.
4. I may inspect or copy any information used or disclosed under this agreement.
5. I authorize the release of medical information to other physicians and/or facilities involved in my health care.
6. I understand that if the person or organization that received the information is not a healthcare provider, the information described above may be redisclosed and would no longer be protected under these regulations.
Patient's First Name:
Patient's Last Name:
Patient's Date of Birth:

MonthDayYear
Date of Birth
I voluntarily authorize the disclosure of information from my health record to myself and other entities involved in my care.
Signature:*

Clear
Signature Date:

MonthDayYear
Date
You have the right to inspect and copy your own health care information, and that of an individual of whom you are a legal guardian or next of kin. Please provide the necessary information to access your lab results or simply decline this service below.
SELECT HOW YOU WOULD LIKE TO ACCESS YOUR RESULTS

Select one of the options below:
PATIENT PORTAL ACCESS ->

View all of your lab results online through our secure patient portal
PATIENT PORTAL ACCESS
Provide your E-Mail address to receive a registration code to view all of your lab results online through our secure patient portal
MAIL RESULTS ->

Receive results via mail at your address on file within 2 weeks of result completion. *This service costs $2.00 as the time of specimen collection*
DECLINE ACCESS ->

I decline access to my own lab results
I am requesting my own informationI am next of kin requesting on behalf of the patient and our relationship is:
Should be Empty:

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

I voluntarily authorize the disclosure of information from my health record to myself and other entities involved in my care.

SELECT HOW YOU WOULD LIKE TO ACCESS YOUR RESULTS