Healthcare Analysis Request Form

HEALTHCARE ANALYSIS REQUEST FORM

Patient Information

Date of Birth:    Gender: Male Female Other Prefer not to say

Insurance Information

Clinical and Medical History

Specimen and Test Request

Specimen ID:    Collection Date:

Specimen Type: Blood Urine Tissue Swab Other

Special Handling: Refrigerated Frozen Room temperature Fixed

Complete Blood Count (CBC) Metabolic Panel Microbiology Culture Histopathology Molecular Analysis Toxicology

Billing, Payment, and Administrative Authorization

Billing Responsibility: Patient Insurance Third party

By signing below the patient or authorized signer certifies that they request the analyses specified above and authorize performance of such analyses. The signer authorizes release of results and supporting reports to the referring provider and to the designated recipients listed on this form, and authorizes assignment of benefits to the performing laboratory where permitted. The signer accepts financial responsibility for charges not covered by insurance and understands that payment may be required prior to release of non-covered results.

Privacy, Use, and Release Authorization

Authorization to Use and Disclose Protected Health Information: I authorize the performing laboratory and its agents to use and disclose my protected health information, including clinical information and test results, to the referring provider, designated recipients, insurance carriers for payment and reimbursement, and other health care providers as necessary for treatment, payment, and health care operations. I understand that some analyses may generate genetic, infectious disease, or other sensitive information and consent to their processing for the specified analyses.

Right to Revoke: I understand that I may revoke this authorization at any time by submitting written notice to the performing laboratory, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made in reliance on this authorization.

Limitations and Liability: The performing laboratory will exercise reasonable care in the handling and analysis of specimens. The laboratory is not liable for delays or loss of integrity due to factors beyond its control, including improper specimen collection, labeling, or transport. The laboratory's liability for errors shall be limited to correction of the error, repeat analysis, or refund of fees at the laboratory's discretion.

I acknowledge receipt of the laboratory's privacy practices and understand my rights regarding my protected health information.

This authorization will expire on:    If left blank, this authorization will remain in effect for one year from the date of signature unless revoked earlier.

Certification and Signature

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I authorize the requested analyses and the release of results as described above. I understand that withholding clinical information or specimen history may affect the interpretation of results.

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