CoreMD Clinic
Patient Authorization for Release and Receipt of Diagnostic Results

1. Purpose of Authorization

I hereby authorize the secure release and transmission of my diagnostic health information to CoreMD Clinic for the purpose of clinical review, structured interpretation, and ongoing health insights.

This authorization is intended to facilitate continuity of care, enhance my understanding of my health data, and support preventive health strategies.

2. Information to Be Disclosed

I authorize the release of the following health information, where applicable:

• Laboratory test results (including but not limited to blood work, urine tests, and other diagnostic panels)

• Imaging reports (including X-rays, ultrasounds, CT scans, MRI studies)

• Cardiac and diagnostic testing (including ECG, echocardiogram, Holter monitor reports, stress tests)

• Other non-urgent diagnostic investigations relevant to my health

This includes both historical and future results, unless otherwise specified.

3. Authorized Sources

I authorize the release of my health information from:

• Diagnostic laboratories (including but not limited to LifeLabs and Dynacare)

• Hospitals and imaging centers

• Referring or primary care physicians

• Other licensed healthcare providers or diagnostic facilities involved in my care

4. Recipient of Information

I authorize that all relevant diagnostic results be securely transmitted to:

CoreMD Clinic
[Insert clinic address]
[Insert secure fax / EMR / secure email]

CoreMD Clinic may receive this information through secure electronic medical record systems (including TELUS PS Suite EMR), secure fax, or encrypted digital communication platforms.

5. Use of Information

I understand that my information will be used for:

• Clinical review and interpretation

• Structured explanation of diagnostic findings

• Preventive health guidance and longitudinal health monitoring

• Integration into CoreMD Clinic’s clinical and digital health platforms (including CoreMD Insights)

I acknowledge that this service is intended to complement, not replace, my primary healthcare provider.

6. Consent and Circle of Care

I understand that by providing this authorization:

• CoreMD Clinic may become part of my healthcare “circle of care” where applicable

• My information will be handled in accordance with applicable privacy legislation, including the Personal Health Information Protection Act (PHIPA), Ontario

7. Risks and Safeguards

I understand that:

• CoreMD Clinic will take reasonable steps to protect my personal health information using secure systems and safeguards

• No system is completely risk-free, but appropriate administrative, technical, and physical protections are in place

8. Voluntary Consent and Withdrawal

• This authorization is voluntary

• I may withdraw my consent at any time by providing written notice to CoreMD Clinic

• Withdrawal will not affect information already collected or processed prior to the withdrawal

9. Duration of Authorization

This authorization remains valid:

☐ For a period of ______ months
☐ Until withdrawn by the patient
☐ Other: ___________________________

10. Patient Acknowledgment

I confirm that:

• I have read and understood this authorization

• I have had the opportunity to ask questions

• I voluntarily consent to the release and receipt of my diagnostic information as outlined above

Patient Name: ___________________________

Date of Birth: ___________________________

Signature: ___________________________

Date: ___________________________

Contact Information (Optional):
Phone: ___________________________
Email: ___________________________