Request Lab or Test Results
Full address on file. Street, City, State, Zip
Include area code
Date of Birth
Valid email address
Who is your physician or provider at our office?
Labs? CT? Other testing, please describe.
Where was the test obtained
Name and location of test. Example Blood draw, x-ray, and lab/testing location.
Please detail the reasons for this request.
Authorization to Call or Mail
I authorize you to call or mail the results to my phone/address on file.
I authorize you to MAIL my results to my address on file.
I authorize you to CALL me with my results AND AUTHORIZE you to leave a detailed voicemail with results.
I authorize you to call me with my results, but DO NOT LEAVE A VOICE MESSAGE with my results.
Use of this form constitutes your agreement to be bound by CareSubmit’s
. Please note that
your provider’s HIPAA privacy policies
may also apply to information you disclose on this form.
DO NOT USE THIS FORM FOR URGENT MATTERS. IF YOU ARE HAVING AN EMERGENCY, DIAL 911. We may be required to call you at your number on file and make other confirmations before a request can be processed. Please give our staff up to 24 hours during normal non-weekend non-holiday business hours to complete your request.
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