Form AS0-1-0 "Patient Request for Release of Completed Laboratory Results" - Mississippi

What Is Form AS0-1-0?

This is a legal form that was released by the Mississippi Department of Health - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 30, 2014;
  • The latest edition provided by the Mississippi Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form AS0-1-0 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Health.

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Download Form AS0-1-0 "Patient Request for Release of Completed Laboratory Results" - Mississippi

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PATIENT REQUEST FOR RELEASE OF COMPLETED LABORATORY RESULTS
See page 2 for complete instructions
In order to assure patient identification in compliance with the Health Insurance Portability and
Accountability Act (HIPAA), the Mississippi Public Health Laboratory (MPHL) requires the
completion of the following information:
Patient Name
Date of Birth
Street Address
City, State, Zip
Provider
Type of Test(s)
Name of physician office, hospital or health department where test was collected:
Date(s) when test collected:
A copy of one of the documents listed below must be included with the completed form:
a valid Driver’s license; ID card issued by federal, state, or local government; Passport; School ID card with photograph;
original or certified birth certificate
I understand that this request is valid for the patient listed above and all results documented on this request will be released to the
person signing this document. I understand MPHL records will contain personal healthcare information and when released
MPHL is not liable for distribution beyond this signed request. If this document is not signed MPHL will not be able to process
the request and results will not be provided.
Signature
Print Name
Date:
If parent, guardian, or personal representative: print your name and relationship: Submit a copy of your
healthcare or durable Power of Attorney.
Print Name
Signature
Relationship to patient
Send results by:
Mail __ Fax __ Fax # ______________________ Phone # _____________________
Name and Address information if report is sent to an alternate address
Name
FOR MPHL STAFF ONLY:
Received
/
/
Completed
/
/
Address
Sent:
Fax
Mail
Staff completing request
City, State, Zip
Form # AS0-1-0
12/30/14
PATIENT REQUEST FOR RELEASE OF COMPLETED LABORATORY RESULTS
See page 2 for complete instructions
In order to assure patient identification in compliance with the Health Insurance Portability and
Accountability Act (HIPAA), the Mississippi Public Health Laboratory (MPHL) requires the
completion of the following information:
Patient Name
Date of Birth
Street Address
City, State, Zip
Provider
Type of Test(s)
Name of physician office, hospital or health department where test was collected:
Date(s) when test collected:
A copy of one of the documents listed below must be included with the completed form:
a valid Driver’s license; ID card issued by federal, state, or local government; Passport; School ID card with photograph;
original or certified birth certificate
I understand that this request is valid for the patient listed above and all results documented on this request will be released to the
person signing this document. I understand MPHL records will contain personal healthcare information and when released
MPHL is not liable for distribution beyond this signed request. If this document is not signed MPHL will not be able to process
the request and results will not be provided.
Signature
Print Name
Date:
If parent, guardian, or personal representative: print your name and relationship: Submit a copy of your
healthcare or durable Power of Attorney.
Print Name
Signature
Relationship to patient
Send results by:
Mail __ Fax __ Fax # ______________________ Phone # _____________________
Name and Address information if report is sent to an alternate address
Name
FOR MPHL STAFF ONLY:
Received
/
/
Completed
/
/
Address
Sent:
Fax
Mail
Staff completing request
City, State, Zip
Form # AS0-1-0
12/30/14
Page 2 of 2
PATIENT REQUEST FOR RELEASE OF COMPLETED LABORATORY RESULTS
Final laboratory test reports are issued only to the person on whom testing was performed, to the
person who consented to have the testing performed, or if under 18, to a parent/guardian, or the
person authorized by the patient to receive the results.
Only laboratory reports performed in the Mississippi Public Health Laboratory (MPHL) will be released to
the appropriate person after review and approval of the required documents as part of this request. A
request for laboratory reports performed in the MPHL should not be considered a request for a complete
patient’s medical records file.
The laboratory reserves the right to contact the ordering provider/submitter as needed to verify the
authority and identity of the person requesting the laboratory test report.
The laboratory has up to 30 days from the time the request has been received to provide laboratory
test reports directly to the patient. This allows time for the ordering provider/submitter to review
the results and provide treatment, if required.
THE LABORATORY IS NOT RESPONSIBLE FOR INTERPRETING LABORATORY
TEST RESULTS. If you have questions about the t e s t results, please contact your medical
provider.
Instructions: In order to provide your results, we must verify your identity to ensure that we are not
violating healthcare privacy laws.
1. Submit a copy of one of the following identification documents with this completed form:
Driver’s license
ID card issued by federal, state, or local government
Passport
School ID card with photograph
Original or certified birth certificate
2. If you are the parent or guardian of a patient under 18 years of age for whom you are requesting a
laboratory test result, please provide proof of adoption or guardianship in addition to your
identification documentation.
3. If you are the personal representative of the patient, please submit a copy of your healthcare or durable
Power of Attorney.
4. Mail the completed forms and required documents to:
Lab Document Controller/Records Request
Mississippi Public Health Laboratory
570 East Woodrow Wilson, U-234
Jackson, MS 39216
Or Fax to:
601-576-7037, Attention: Records Request
Please allow 30 days for the request to be processed and returned to you. If you have questions, call
601-576-7582.
Form # AS0-1-0
12/30/14
Page of 2