Authorization for Release for Records

I, [Patient Name], hereby authorize representatives of Fast Lab Technologies LLC., to receive any and all records and information pertinent to any claim or insurance benefit for the provided medical services that I am requesting approval for or seeking payment be issued. This request includes records and information related to ‘sensitive’ health information. I authorize my Insurance Company to release these records pertinent to the services provided by Fast Lab Technologies to any third party deemed necessary. Moreover, I understand, agree, and allow Fast Lab Technologies LLC. to use and release my information as I have stated above. I also understand that signing this consent is of my own free will. I have the right to withdraw this approval at any time by giving written notice of my withdrawal to Fast Lab Technologies LLC. I understand that I cannot cancel this approval when this form has already been used to disclose information.

I understand that my withdrawal of this approval will not affect any action taken before I do so. I also understand that information that’s released may be given out by the person or group who receives it. If this happens, it may no longer be protected under the HIPAA Privacy Rule. I am entitled to a copy of this consent.