Slide Request Form (Draft 1)

REQUEST FOR RELEASE OF ANATOMIC PATHOLOGY MATERIAL

In accordance with federal, state, and local statutes and regulations, including the Clinical Laboratory Improvement Amendments of 1988 (“CLIA”) and Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), I hereby request Gastroenterology Specialties to release laboratory test results and materials for patients that have been referred for medical services at our facility. The laboratory results and materials will be sent via overnight delivery service usually within 3-5 business days from receipt of the completed requests to the address that is designated on this form.

I understand that by signing this request I will be responsible for the proper use and confidentiality of the health care information requested, including HIV/AIDS diagnosis/treatment records and genetic testing/results information. Drug and alcohol abuse information are specifically protected by federal and/or state regulations, and I will not receive any drug and/or alcohol information records.

This request is continuing in nature and is to be given full force and effect to release any and all of the foregoing information learned or determined after the date hereof. I understand that I may obtain a copy of this authorization form for my records if requested.

Patient Name:

Patient Date of Birth:

Record Number:

Date:

PLEASE ATTACH A COPY OF THE PATHOLOGY REPORT TO THIS REQUEST.

REASON FOR REQUEST (check one):

Transfer of care to another institution or physician

Patient requesting second opinion on pathologic diagnosis (will also need

patient release of information form)

Physician requesting second opinion on pathologic diagnosis

Other (specify)

Name and contact information of person filling out this form:

PLEASE ATTACH A COPY OF THE PATHOLOGY REPORT TO THIS REQUEST.

I hereby request GASTROENTEROLOGY SPECIALTIES to release anatomic pathology results and materials to the following:

Physician or designee:

Name of facility:

Address:

City, State, Zip:

Phone number (required):

Please fax completed form to (402) 465-3560, GASTROENTEROLOGY SPECIALTIES, Attn. Histology Lab.