DISCOUNT BLOOD TESTING - RELEASE FORM

Name: ________________________________, __________________________
           Last                                                            First
Address:_________________________________________________________

Telephone: (Home) ___________________  (Cell) _______________________

Email: ____________________________________________

I have read and understand your HIPAA policy and privacy disclaimer.

SPECIFIC AUTHORIZATIONS
Your results will not be released to a third party unless you specifically authorize it 
by checking the box below:
□ I would like the following person to receive a copy of my DiscountBloodTesting.com 
lab results and hereby give you the authority to disclose that information to said person(s).

Name: ________________________________, __________________________
            Last                                                           First
Address:_________________________________________________________

Telephone: (Home) ___________________  (Cell) _______________________

Email: ____________________________________________
□ I specifically authorize release of information pertaining to Drug Screen Results; and,
□ I specifically authorize the release of HIV/AIDS testing information.
□ Please send me a copy of my laboratory results via email.

Signature:____________________________________________
This authorization will automatically expire in 6 months. I may revoke this authorization
at any time, provided I do so in writing and submit same to DiscountBloodTesting.com.
The revocation will take effect as it is received by DiscountBloodTesting.com.

Please FAX this completed form along with a copy of your DRIVER'S LICENSE.

Name: ______________________________, __________________________
            Last  (Please Print)                               First  (Please Print)

Thank You!

NOTICE: Federal and State laws require keeping health information confidential. If 
you have authorized the disclosure of your personal health information to someone 
who is not legally required to keep it confidential, it may no longer be protected by 
those State or Federal confidentiality laws.