I authorize the following protected health information to be released from my medical record(s) on Date of Service: • COVID-19 Results
I authorize that my protected health information (PHI) from this facility be disclosed to:
Recipient First & Last Name Recipient Address City State Zip Recipient Email Recipient Phone Number Fax (healthcare provider/facility only)
By signing this authorization form, I understand that:
I UNDERSTAND THAT I MAY INCUR FEES FOR RECEIVING COPIES OF MY MEDICAL RECORDS. FEES FOR COPIES OF MEDICAL RECORDS ARE REGULATED BY THE STATE OF MICHIGAN. Patient Acknowledgement I voluntarily consent to the collection and testing of my specimen. I consent to the release of any medical records necessary to process claim(s).
Integrated Laboratory Providers
26154 Woodward Ave, Royal Oak MI 48067
248-619-4372