Healthcare Labs Review

Healthcare Labs Review

Patient Information

Patient Name:   Date of Birth:

Medical Record Number:   Gender:

Insurance / Billing

Lab Order & Specimen

Ordering Provider:   Order Date:

Specimen Type:   Collection Date/Time:

Tests Reviewed

Please mark all laboratory tests reviewed during this encounter:

Results Summary & Clinical Findings

Abnormal result(s) noted requiring immediate action or contact

Recommendations & Follow-Up

Patient Education & Communication

Privacy, Authorization & Acknowledgment

I acknowledge that the laboratory results and this review have been discussed with me as indicated above. I understand the clinical interpretation provided may require additional testing or follow-up. I authorize the release of these laboratory results to other treating providers and to the patient record as necessary for treatment, payment, and healthcare operations unless otherwise restricted by formal legal order.

I acknowledge receipt of the facility's privacy practices and that I may request a copy of my laboratory report.

I authorize release of my laboratory results to third-party providers as indicated for continuity of care.

I certify that the information recorded on this Healthcare Labs Review is true to the best of my knowledge and that I have been offered an opportunity to ask questions. I understand that I may withdraw this authorization in writing except to the extent that action has already been taken in reliance on it.

Reviewed By (Clinician)

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