Paternity Testing Form
PRINT NAME
PROGRAM CASE NO.
DATE OF BIRTH AND LOCATION
RELEASE OF PATERNITY TESTING RESULTS
AUTHORIZATION TO DISCLOSE PATERNITY TEST RESULTS OF:
OTHER IDENTIFICATION NUMBER
LABORATORY CASE NUMBER (IF KNOWN)LABORATORY NAME
LABCORP
WITNESS/NOTARY PUBLIC (SIGN & PRINT NAME, IF APPLICABLE)
Alleged Father Signature Today’s Date
Child’s Parent or Guardian Signature
DATE OF BIRTH
Today’s Date
(CHILD’S NAME) LAST FIRST MIDDLE
I have submitted, or am submitting, to the genetic testing of my DNA to determine whether I am the
biological father of the above-named child. I hereby authorize the laboratory that performs this DNA analysis
to release the results, and any accompanying affidavit regarding the test results, to the Tulalip Tribes
beda?chelh, Tulalip Child Support Program and Tulalip Tribal Enroll
ment Department. I also hereby
autho
rize any one of these three tribal programs that receives my genetic test results to share the results with
the other two tribal programs. This information may be provided verbally, or by computer data transfer,
mail, fax, or hand delivery. This release is valid for two years from the date signed below. A copy of this form
shall be considered as valid as the original. I acknowledge that if I am determined to be the father of the child,
that the tribal agency will move to amend the bir
th certificate in court; I waive notice of such presentment to
estab
lish paternity in a court of law.
If I am not the person who is the subject of this release of paternity test results, I am authorized
to sign this release on that person’s behalf because I am the: (attach proof of authority)
Parent of minor Legal Guardian/Custodian Attorney/Legal Representative
Other:
I understand that my records are protected under the federal and state confidentiality regulations (42 CFR, Part 2) and cannot be disclosed without my
written consent unless otherwise provided for in the regulations. I understand that information disclosed by this authorization may be subject
to
redisclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act (HIPAA, 45 CFR, part 164.
I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. I further acknowledge that
the information to be released has been fully explained to me and this consent is given of my own free will. If
client is less than 13 years of age, a
p
arent or legal guardian must sign consent.
OFFICE USE ONLY:
*Test Can Be Completed before
Payment is Received HOWEVER
results WILL NOT be released until
payment is received in full.
PAID AMT:
DATE PAID:
REC’D BY:
* If a paternity test is not performed for the purposes of Tulalip Tribes Enrollment or Tulalip Cour
t
O
rdered, the client(s) will need to provide a fee of twenty-five ($25.00) dollars per person to test
.
[
i.e. Baby and Dad would cost $50.00]. We do not carry cash, need exact change *
(FATHER MIDDLENAME) LAST FIRST
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signature
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