Please Select Insurance Type and add Primary Insurance Provider for Testing Options
Physician Certification: This test is medically necessary for the risk assessment, diagnosis or detection of a disease, illness, impairment, symptom, syndrome or disorder. The results will determine my patient’s medical management and treatment decisions. By my signature below, I indicate that I am the referring physician or authorized health care provider. I have explained the purpose of the test. The patient has been given the opportunity to ask questions and/or seek further counsel. The patient has voluntarily decided to have the test performed by Lab. As the medical provider, I am responsible for documenting applicable ICD-10 diagnosis codes.
For non-touch screen devices, the patient needs to type their full name below, and provide a secondary identifier.
By selecting the Add Signature button, I attest that I approve of this digital signature
I am voluntarily seeking laboratory service and hereby consent to provide a sample as requested. I have the right to refuse testing, but I understand this may impact my treatment. This agreement can be revoked by me at any time with written notification and is valid until revoked. I hereby assign to the laboratory my right to insurance benefits that may be payable to me for services provided arising from any insurance policy, self-insured health plan, Medicare or Medicaid in my name or on my behalf. I further authorize payment of benefits directly to the laboratory. I understand acceptance of insurance does not relieve me from any responsibility concerning payment for laboratory services and that I am financially responsible for all charges whether or not they are covered by my insurance. I understand that any payment I receive for services rendered by the laboratory from my insurance provider should be forwarded to the laboratory immediately.
Physician Signature / Date
Patient Signature / Date
I hereby request and authorize the laboratory or its affiliates to utilize this information to perform testing for the indicated patient. I certify that I have explained the test to the patient. I also certify that I will only use and disclose test results as permitted by law. I certify that the tests ordered on this form are medically necessary and on the basis of the patient’s clinical condition as part of my treatment plan. I understand that Medicare, Medicaid and other insurance companies will only pay for tests that meet the payer’s coverage criteria and are reasonable and necessary to treat or diagnose the patient. I will document the order for these clinical diagnostics tests in the patients chart and that will serve as documentation of my order. I agree to provide copies of medical records to the testing laboratory upon request.
Hl7 file has already sent , do you want to resend hl7 file?