AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
AFTER COMPLETING THIS FORM, PRINT & FAX TO:

DirectAccessLab
FAX: 1-866-479-1380

or mail to:
11811 North Tatum, Suite 3031 Phoenix, AZ 85028
                                                                                                                                                                   

Today's Date:

Patient Number: (DLS Use Only)

First Name:

Last Name:
Address:
City, State, Zip:
Email Address:
Date of Birth:

Home Telephone:

I authorize DAL to release health information electronically (email or fax) or paper to:

__________________________________________________________________
Name of person or facility to receive health information

___________________________________________________________________
Street Address, City, State, Zip Phone


INFORMATION TO BE RELEASED

Laboratory Report(s) Date of Report_________________Requisition #___________________
Billing Statements

SPECIFIC AUTHORIZATIONS
The following information will not be released unless you specifically authorize it by marking the relevant box(es) below:

I specifically authorize release of information pertaining to drug and alcohol abuse or treatment
I specifically authorize the release of HIV/AIDS testing information
PURPOSE OF THIS RELEASE                                                  EXPIRATION OF AUTHORIZATION
At the request of the patient/patient representative         (DATE)_________________
Continuity of care                                                               Will expire in 12 months if not
Other_____________________________________        indicated above

NOTICE
DAL and other health organizations are required to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.

MY RIGHTS
*I understand this authorization is voluntary. Treatment may not be conditioned on signing this authorization except if the authorization is for: 1) conducting research-related treatment, 2) creating health information to provide to a 3rd party.
*I may revoke this authorization at any time, provided I do so in writing and submit to DirectAccessLab 300 Mariners Plaza Suite 320 Mandeville, LA 70448. The revocation will take effect when DAL receives it.
* I am entitled to receive a copy of this Authorization.

SIGNATURE

__________________________________                         Date________________________
(Signature of Patient or Patient's legal representative)

Printed Name___________________________

If signed by someone other than the patient, state your legal Relationship to the patient:

______________________________________


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