Please Select Insurance Type and add Primary Insurance Provider for Testing Options
I am authorized to order laboratory tests and hereby order the tests indicated below. I confirm these test(s) are medically necessary for the treatment of the patient. I supplied accurate and true information on this form. I am aware information has been supplied to the patient about drug testing and that the patient has consented to the testing through his/her signature on this form. I understand that it is my responsibility to document medical necessity for testing in the patient record and to provide a copy of the same to Labs upon request.
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 supplied accurate and true information with this form. If I supplied insurance information, I authorize payment of my insurance benefits directly to Labs. I authorize Labs to be my Designated Representative and to appeal any denial of health benefits. I understand Labs may be out of network with my plan, and I accept responsibility for paying to Labs any amounts my insurer determines are my responsibility after calculating deductibles, co-payments and co-insurance due under my policy. I understand I am legally responsible for sending Labs any money received from my health insurance company for performance of this laboratory test. I also allow the release of medical information necessary to process this claim.
Specific Site Analysis
Positive Control Not Available
Positive Control Sent/To Be Sent
Do not include BRCA1/2 sequencing results for this multi-gene panel order due to previous negative testing for this patient through another diagnostic laboratory. PLEASE NOTE: a copy of the previous negative BRCA1/2 report MUST be included with the test requisition form for BRCA1/2 sequencing results to be excluded from the final Aeon Clinical Laboratories report. In addition, clinically significant BRCA1/2 variants(i.e.those classified as “pathogenic” or “likely pathogenic”) are always reported.
Physician Signature / Date
Patient Signature / Date