Patient Authorization and Consent Form
Patient’s Full Name: …………………………………………………………………………………………………………………………….
Date of Birth: …………………………………………………………………………………………………………………………….
Social Security Number: XXX-XX-…………………
Authorization for Release of Medical Information
I hereby authorize the following institution(s) and healthcare provider(s):
(Insert the name(s) of the hospital, clinic, or healthcare provider)
to release and disclose the complete set of my medical records, including but not limited to:
- Office notes
- Consultation reports
- Pathology reports
- Laboratory results
- Imaging studies (X-rays, MRIs, CT scans, PET scans)
- Surgical reports
- Medication records
- Psychological or psychiatric evaluations
- Information relating to sexually transmitted diseases (STDs), acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV)
- Alcohol and drug abuse treatment records
- Other relevant medical information
The purpose of this authorization is to allow Stellar Pathology to conduct a comprehensive diagnostic evaluation, including, if necessary, further pathology studies. I understand that the medical records released will be used for diagnostic and consultation purposes only.
Authorization for Additional Pathology Studies
I authorize Stellar Pathology and its representatives to perform additional pathology studies on my previously collected tissue samples, medical records, or other relevant materials, as deemed necessary for accurate diagnostic evaluation. This includes but is not limited to histopathological evaluations, immunohistochemistry, molecular studies, and genetic testing.
Limitation on Disclosure
I understand that the information disclosed by the authorized institutions may be shared with Stellar Pathology and its representatives solely for the purpose of providing consultation and diagnostic services. No further disclosure of my personal health information will occur without my explicit written consent, except where required by law.
Consent for Electronic Transmission of Medical Records
I understand that my medical records may be transferred electronically, including through fax, email, or other secure electronic communication methods, in compliance with HIPAA regulations. I acknowledge the potential risks associated with electronic transmission and consent to the use of these methods.
No Guarantee of Outcome
I understand that the second opinions and additional studies conducted by Stellar Pathology are intended to supplement the diagnosis and treatment plan of my primary healthcare provider. They do not replace or supersede the recommendations of my treating physician or medical team.
Revocation and Expiration
I understand that I have the right to revoke this authorization at any time by submitting a written request to Stellar Pathology. I also understand that any revocation will not affect any actions taken prior to the receipt of the revocation.
Unless earlier revoked, this authorization will expire two (2) years from the date of signature.
Right to Refuse
I understand that I am not required to sign this form and that my treatment or payment for my healthcare will not be conditioned upon my signing of this authorization.
Contact Information
For questions or to submit a revocation request, please contact Stellar Pathology at:
Phone: +1 (888) 818-2158
Email: info@stellarpathology.com
Patient Acknowledgement and Signature
I, the undersigned, acknowledge that I have read and fully understand the above authorization and consent form. I voluntarily agree to allow Stellar Pathology to access my medical records, perform additional pathology studies if necessary, and disclose relevant information as outlined above. I also understand that I may revoke this consent at any time as stated in this document.
Patient’s Signature: ………………………………………………………………………………….
Date: ………………………………………………………………………………….
Patient’s Address: ………………………………………………………………………………….
Phone Number: ………………………………………………………………………………….
Email Address: ………………………………………………………………………………….
Signature of Legally Authorized Representative (if applicable):
Name: ………………………………………………………………………………….
Relationship to Patient: ………………………………………………………………………………….
Date: ………………………………………………………………………………….
Phone Number: ………………………………………………………………………………….
Witness Signature (optional):
Name: ………………………………………………………………………………….
Signature: ………………………………………………………………………………….
Date: ………………………………………………………………………………….
Minor Patient Authorization (if applicable)
Signature of Minor Patient: ………………………………………………………………………………….
Date: ………………………………………………………………………………….
This form is compliant with HIPAA regulations and 45 CFR § 164.508, ensuring the proper handling of patient health information.
