Patient Forms

Records Release Authorization

Before your appointment, we need your written permission to request your lab order from your doctor and to confirm your specimen was received by the lab. This form takes two minutes and stays valid for one year.

Fill out online

Complete the form below, then click "Print / Save as PDF" to download your filled copy.

Download blank form

Prefer to print and fill by hand? Download the blank PDF.

Download blank PDF

Doctor's Orders Mobile Collection Services

Records Release Authorization

Valid for one year from date signed · getmyblood.com

Patient Information

Full legal name *

Date of birth *

Phone number

Email address

Street address

City

State

ZIP

Ordering Provider (Doctor / Clinic)

Provider or clinic name

Provider phone

Provider fax

Laboratory

Lab name (if known)

Authorization *

I authorize Doctor's Orders Mobile Collection Services to contact my ordering provider to obtain my lab order and to confirm that my specimen was received by the laboratory.I understand this authorization is valid for one year from the date signed and may be revoked in writing at any time.

Signature *

Type your full name to sign *

Typing your name constitutes your legal electronic signature.

Date *

Relationship to patient

Email and text message are not fully secure. By sending your signed form by email or text, you accept that risk. You may also hand a signed paper copy to your phlebotomist at your appointment instead. We will need to see the photo ahead of time.

Download blank PDF

Complete the required fields (*) and check both authorization boxes to enable printing.

What you're authorizing

Signing this form lets us do the legwork for you. It gives us your written permission to contact your doctor's office and your lab directly, request your lab order, confirm your specimen was received, and follow up if anything needs to be redrawn. Without it, offices are not allowed to release anything to us and you would have to chase the paperwork yourself.

Request your lab order from your doctor's office
Deliver your specimen to the lab you choose
Confirm the lab received and accepted your sample
Arrange a redraw if a sample is rejected

The form is valid for one year and you can revoke it at any time in writing. It does not allow us to make medical decisions for you or access records unrelated to your lab work.

How to submit your completed form

1Fill out the form above and click "Print / Save as PDF" to download your completed copy.
2Email your completed form to [email protected] or text a photo to 941-531-1636.
3Prefer paper? Download the blank PDF, print and sign it, then bring it to your appointment or send it ahead of time.