Client Authorization

Client Authorization Form for Bloodwork Analysis
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Authorization for Use or Disclosure for Protected Health Information
- I authorize my practitioner and My Blood Chart LLC, to order my bloodwork labs (unless I am obtaining them on my own), receive the results and use the results to create an analysis report.
- I understand that all of my healthcare information will remain confidential and used only for purposes agreed upon.
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Client Authorization Form for Bloodwork Analysis