Request for Release of Pathology Services, P.C.

Diagnostic Specimens and Reports

Pathology Services, P.C.
P. O. Box 1289
North Platte, Nebraska 69103-1289
Phone: 308-532-4700

Patient's Name:___________________________________________________

Social Security Number:______________________________

Date of Procedure:__________________________________

Type of Specimen:__________________________________

Accession #(s), if known:_____________________________

Physician:_________________________________________

Person Requesting Release:____________________________

Relationship to Patient:________________________________

Home Phone Number:________________________________

Work Phone Number:________________________________

Fax Number:_______________________________________

E-mail:___________________________________________

Driver's License Number: ___________State: ______

Action Requested:

Release of report

Release of slides

Release of tissue blocks

Person to Receive Delivery: _____________________________________________________________

Telephone Number: _______________________________________

Fax Number: _______________________________________

E-mail address: _______________________________________

Purpose of Delivery:

Further therapy

Consultation

Legal action

Other:______________________________________

Date Required: _______________________________________

Special Instructions: ________________________________________________________________

________________________________________________________________

By submitting this request, I assume full responsibility for the custody of the slides and/or tissue blocks, if received.

The slides and tissue blocks are the property of Pathology Services, P.C. and must be returned

within 30 days. The patient or the authorized patient representative may receive the slides and tissue blocks

at any time when a valid request is submitted.

_______________________________________ ______________________

Signature                                                                 Date

_______________________________________

Relationship to Patient

Processing Instructions:

Bring this completed form to Pathology Services, P.C. You will be required to show personal identification or power of attorney before being allowed to pick up specimens or reports.