This form is to allow us to release test results or other health information directly relevant to your ongoing care to whomever you authorize. This is not a release of medical records. This information will be used in the event that you are not available to receive your test results or other care information and would like that information given to a designated person; for example, your parent, aunt, grandparent. THIS IS NOT A MEDICAL RELEASE FORM.
This authorization is valid for one year, unless updated and initialed by the patient.
Test results may be released to the following: