Request for Release of Lab Results

This request aligns with HIPAA regulations, particularly the HIPAA Privacy Rule, which grants individuals the right to access their health information, including laboratory test results. Under HIPAA, laboratories are considered covered entities, meaning they must provide patients with access to their results upon request.

However, compliance depends on ensuring:

• Proper authorization: The request must be signed by the individual or their authorized representative.

• Secure transmission: The results should be shared through HIPAA-compliant methods, such as encrypted email or secure portals.

• Notice of Privacy Practices (NPP): The laboratory should have an updated NPP reflecting patients' rights to access their results.

If The Aether Loop follows these safeguards, the request should be compliant.

Request for Release of Laboratory Test Results
June 2025

I hereby request that The Aether Loop, Inc release to me all completed test results arising out of my receipt of laboratory services from SiPhox Health, as accessed via The Aether Loop, Inc. (the “Results”).

I hereby acknowledge and accept that:
(a) Either prior to or simultaneous with the communication of the Results to me, the Results will be communicated to the physician who ordered the laboratory test(s) resulting in the Results (the “OP”);
(b) The communication of the Results to me should not be viewed as medical advice and is not meant to replace direct communication with the OP;
(c) All inquiries regarding the meaning and/or interpretation of the Results should be directed to the OP; and
(d) The communication of the Results does not include any information which would be consideration given for referrals, including medical advice specifically directed at me concerning my condition.