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.

I request and authorize the Laboratory to perform the designated test(s) on the sample provided by me. My signature below constitutes my acknowledgment that I have been informed of the benefits and limitations of this testing which have been explained to my satisfaction by a qualified health professional. I also understand that the laboratory or laboratories involved in my care reserve the right to provide de-identified information of a statistical nature to accrediting agencies and reserve the right to use such anonymous information In compliance with Section 102.006 of Texas Occupation Code.