Please Select Insurance Type and add Primary Insurance Provider for Testing Options
I hereby assign all applicable health insurance benefits and/or insurance reimbursement I have under my health plan(s) to for services performed by . I also appoint Company as my authorized representative and convey to Company to the full extent permissible under the law, the power to: (1) file medical claims with the health plan; (2) file appeals and grievances with the health plan and/or any agency or governmental body with applicable authority; (3) obtain and release, medical records and insurance information as necessary to process a claim, appeal or grievance; and (4) collect payment of any and all medical benefits and insurance proceeds (including Medicare and Medicaid). The above appointment and conveyance include all my rights in connection with any claim, right, or cause of action including litigation against my health plan that I may have, including, the right to claim on my behalf, all such benefits, claims, or reimbursement, and to seek any other applicable remedy, including fines.
By signing below, I authorize the release of my clinical specimens and electronic health, record information that are requested by , and I hereby direct the pathology lab receiving this request to release and provide all such Materials to . I understand that the Materials may be irreplaceable and could be lost or damaged in handling, transit or when used. I agree to release . and any pathology laboratory releasing such Materials from any claims I may have for any such loss or damage to the Materials.
By signing this form, I acknowledge as the patient that I have had a detailed discussion with my health care provider on the risks and benefits of the MiCheck® Prostate test. This included a discussion of why the MiCheck® Prostate test was being ordered, my other options including prostate biopsy, and potential risks of getting the MiCheck® Prostate test. After this review and discussion, I understand and agree with the need to order the MiCheck® Prostate test.
By submission of this test requisition and accompanying sample(s), I certify that shared decision making occurred with the patient on the risks and benefits of the MiCheck® Prostate test. This included a discussion of the medical necessity of the MiCheck® Prostate test order, other management options including directly undergoing a prostate biopsy, and potential risks for this management plan. After this discussion, and prior to ordering the test, the patient has agreed that the MiCheck® Prostate test is the best option for him. I authorize and direct you to perform the testing indicated and; (i) I am authorized by state law to order the test(s) requested herein; (ii) any custom panel and/or ordered test(s) requested on this test requisition form are reasonable and medically necessary for the diagnosis and/or treatment of a disease, illness, impairment, symptom, syndrome or disorder; (iii) the test results will determine my patient's medical management and treatment decisions of this patient's condition on this date of service; and (iv) the full and appropriate diagnosis code(s) are indicated to the highest level of specificity.
IBy ordering testing, the undersigned person represents that he/she is a licensed medical professional authorized to order diagnostic tests OR is a representative of a licensed medical professional authorized to order diagnostic tests; acknowledges the patient has been supplied information regarding diagnostic testing and the patient has given informed consent for diagnostic testing to be performed and the signed consent form is on file. I confirm that this is medically necessary for the diagnosis or detection of a disease, illness, impairment, syndrome or disorder, and that these results will be used in the medical management and treatment decisions for this patient. In addition, by signing below you confirm that you: (a) have an on-going relationship with the patient, (b) will use the results in the management of the patient's medical condition, (c) will follow up with the patient once the test results are received to render additional treatment decisions based on the test results, (d) will maintain a detailed chart with extensive SOAP notes specifying how the test results impacted the medical care and treatment of the patient in follow-up visits, (e) that you understand that if the patient is a Medicare beneficiary that Medicare does not cover routine screening tests, and (f) that you certify under the penalties of perjury that the test ordered is not a screening test, and that all local and national CMS coverage guidelines to determine medical necessity of the ordered test have been met. For Medicare and Medicare Advantage Beneficiaries: Prior to ordering, I have confirmed that the patient presents with Elevated Prostate Specific Antigen (PSA- ICD-10 Code R97.20) with a PSA > 3 ng/mL.
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
By my signature below, I voluntarily consent to the collection and testing of my specimen and the release of the testing results to the ordering physician/facility, however, such results shall be used solely for clinical and is unadulterated. I authorize SOFT CELL L-FORM LABORATORIES LLC to bill my insurance directly for services I receive and acknowledge that SOFT CELL L-FORM LABORATORIES LLC may be a out-of-network provider with my insurance. I am aware that in some instances my insurer may send payment directly to me. In such instances I agree to endorse the check and forward it to SOFT CELL L-FORM LABORATORIES LLC within 30 days.
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?