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.

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.