Sarapath Diagnostics - Patient PHI Disclosure Request

Authorization to Use or Disclose Protected Health Information(PHI)

In order for us to identify the requested Patient PHI, please complete all required information. Using the information you provide below, we will attempt to identify the requested laboratory test results and/or order form. *Indicates REQUIRED information.

We may deny this request under certain circumstances. We may charge a reasonable, cost-based fee to comply with this request under certain circumstances. If a fee will be charged, we will notify you in advance. If you have any question(s), please contact Patient Services Center toll free at 1-877-362-9144 or at 1-941-362-8900.

SaraPath Diagnostics will respond within 30 days of receipt of this request.

Patient's Information:

First Name*	MI	Last Name*	Daytime Phone Number*

Test Order information:

Approximate Date of Service* (Must be within 60 days from test date)
Date of Service 1.	Ordering Physician	Ordering Physician Address
2.
3.
4.
Requested PHI*(Check at least one) Lab Test Results Lab Order Form

Delivery Instructions for Laboratory Test Results or Lab Order Form:

Send to*	First*	MI	Last*
(Check one below) Check here if address is the same as above

By selecting "Fax" or "Email" below I understand that the requested information will be sent unencrypted, which could permit unauthorized parties to access my information.
Fax Number
Email Address
By selecting "Secure Email" below, I understand that I will be provided with a password that I will need to enter in order to be able to open and view my documents, and will need to provide a phone number to receive the password via an automated phone call or text message.
Secure Email Address Email Verification Phone #

Requestor's Authorization:

You understand that should you have questions relating to the interpretation of your requested laboratory test results, that the ordering physician is responsible for such interpretation. By signing this form, you understand and acknowledge that (i) we will not condition treatment or services on whether you sign this form, except when the provision of health care is solely for the purpose of creating PHI for disclosure to a third party, (ii) information used or disclosed pursuant to this request may be subject to redisclosure by the recipient and may no longer be protected by law, (iii) you may revoke this request at any time by giving written notice to SaraPath Diagnostics, 2001 Webber Street, Sarasota, FL 34239. ATT: Patient Services Center or fax to: 1-941-362-8911 if you desire to do so, (iv) you will not be able to revoke this request in cases where we have already relied on it to disclose your health information, and (v) absent a written revocation, this request wil remain in effect until we provide the requested information. I, the undersigned, being legally authorized to request the above information, certify that the information indicated on this form is true, complete and accurate. I unerstand that my handwritten or electronic signature below shall have the same legal effect as if made under oath. The purpose of this request is at the request of the patient identified in patient information above. NOTE: If you are a legal representative of the patient please provide proof of representation as requested (healthcare proxy, court order, power of attorney, etc.)
Relationship*(Check one) Self Parent Legal Guardian(Provide Proof) Legal Representative(Provide Proof)