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Massachusetts General Hospital
Neurogenetics DNA Diagnostic Lab
CRP Building North
5th Floor, Suite 5240
185 Cambridge Street
Boston, MA 02114
Tel. 617-726-5721
Fax 617-724-9620
Web Page: www.dnalab.org
AUTHORIZATION FOR RELEASE OF PROTECTED OR PRIVILEGED INFORMATION
PATIENT NAME: _____________________________
PATIENT DATE OF BIRTH: ______________
PATIENT ADDRESS: ____________________________________________________________________ ___________________________________________________________________
TELEPHONE #: DAY: ( ) ____________________
EVENING: ( ) _____________________
I ______________________________________________ do hereby authorize Massachusetts General Hospital to release health information including copies of my medical lab report from the MGH DNA Diagnostic Lab to the referring professional and/or to the following person(s) or classes of persons (i.g., doctors, lawyers) at the locations/facilities listed.
Person/Class of Person/Facility/Address (include name and address)
1. _____________________________________
_______________________________________
_______________________________________
_______________________________________
2. _____________________________________ _______________________________________ _______________________________________ _______________________________________
I have carefully read and understand the above, have had any questions explained to my satisfaction, and do herein expressly and voluntarily authorize disclosure of the above information about, or medical records of, my condition to those persons or agencies listed above.
Parent's Signature: ____________________________________
Date: ______________________________
Print Name: ________________________________________________________________________________
When patient is a minor, or is not competent to give consent, the signature of a parent, guardian, or other legal representative is required.
Signature of Legal Representative: _______________________________ Date: _______________________
Print Name: _____________________________________
Relationship: ___________________________