Healthcare Analysis Request

HEALTHCARE ANALYSIS REQUEST

Patient Information

Insurance Information

Medical History

Requested Analysis Details

Analysis Type (check all that apply):

Lab Analysis Pathology Review Genetic Analysis Imaging Review

Data Aggregation / Analytics Other

Specimen / Source (check all that apply):

Blood Urine Tissue Swab

Imaging Electronic Health Record Data Other

Purpose and Use of Results

Purpose (check all applicable):

Clinical Care Second Opinion Research Insurance Claim

Quality Improvement Legal / Forensic Administrative

If research is selected, the requester confirms that separate research authorization has been obtained or will be obtained from the patient or authorized representative prior to release of identifiable information.

Billing and Financial Responsibility

The requesting provider and patient understand and agree that charges associated with analysis, reporting, and special handling will be billed in accordance with applicable policies. The patient or responsible party is ultimately responsible for charges not covered by insurance, including co-payments, deductibles, and services denied by the insurer.

Authorization to Release and Use Health Information

By signing this Healthcare Analysis Request, I authorize the release of my protected health information and specimens to the receiving laboratory or analysis entity for the purpose(s) stated above. This authorization permits disclosure of relevant medical records, images, laboratory specimens, and associated data as necessary to perform the requested analysis. I understand that my information may be used to produce a clinical report and, where applicable and authorized, aggregated de-identified datasets for quality improvement.

I acknowledge that the receiving entity will make reasonable efforts to protect my privacy in accordance with applicable privacy laws. I understand that once information is disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected under my originating provider's privacy policy, except where prohibited by law.

I understand that I may revoke this authorization at any time by providing written notice to the requesting provider, except to the extent that actions have already been taken in reliance upon this authorization. Revocation will not affect disclosures made prior to receipt of the revocation. This authorization will expire on the date specified below or, if left blank, one year from the date of signature.

I certify that the information provided on this Healthcare Analysis Request is accurate to the best of my knowledge and that I have the authority to authorize release of the requested records and specimens. I further acknowledge that I have been informed of alternatives and potential risks associated with the requested analysis where applicable.

I authorize the release and use of my protected health information and specimens for the purposes stated in this form.

I acknowledge receipt of the provider's privacy practices and have been informed of my rights regarding personal health information.

Patient Certification and Signature

By signing below I affirm that I have read and understand this Healthcare Analysis Request, that I authorize the requested analysis and release of information as stated, and that I understand my rights and responsibilities described herein.

Sign Now