Patient Last Name:(Required) Patient First Name:(Required) Date of Birth:(Required) MM slash DD slash YYYY Address:(Required) Phone (Day):(Required) Phone (Night): Physician or Practice that initiated test: Specimen Collection Date (if known): MM slash DD slash YYYY Designee name (if applicable): I designate (the named above) receive my Laboratory Test Results, in my stead. I request Labtech Diagnostics, LLC provide me, or my designee, named above, a copy of my Laboratory Test Results in the format and to the address, etc. below:Unencrypted Email:(Required) 4-Digit Passcode *Numbers onlyFax: Please upload a photo of your government-issued ID(Required)Accepted file types: jpg, png, pdf, Max. file size: 256 MB.I request Labtech Diagnostics, LLC provide a copy of my Test Results, and understand the law requires the laboratory to provide a copy of my Test Results to me within 30 days of the date of my request. As proof of identity, I have enclosed a copy of my driver’s license, or other form of identification. I understand if I request my Test Results to be sent via email, that the email will not be encrypted and anyone with access to my email account (and potentially, those who don’t), may be able to access my Test Results. I understand that these results are for clinical purposes only and should be reviewed by a physicianSIGNATUREDATE:(Required) MM slash DD slash YYYY HiddenOFFICE USE ONLY:HiddenDate Received: MM slash DD slash YYYY HiddenStaff Member Name:
