Healthcare Blood Work Form

HEALTHCARE BLOOD WORK FORM

Patient Information

Patient Name:    Date of Birth:

Phone:    Gender: Female Male Other

Insurance Information

Policy/ID Number:    Group Number:

Clinical Information / Reason for Test

ICD-10 Code(s):    Urgency: Routine Stat / Same Day

Tests Ordered (check all that apply)

Complete Blood Count (CBC)    Comprehensive Metabolic Panel (CMP)    Basic Metabolic Panel (BMP)

Lipid Panel    Hemoglobin A1c    Thyroid Stimulating Hormone (TSH)

Coagulation Panel (PT/INR)    HIV Antibody/Antigen    Hepatitis B Serology

Hepatitis C Serology    Drug Screen    Other:

Collection Details

Specimen Type: Venous Capillary (fingerstick) Arterial Urine

Date/Time of Collection:    Fasting: Yes No    Hours Fasting:

Special Handling / Laboratory Instructions

Consent and Authorization for Blood Draw and Testing

I authorize the collection of blood and/or other specimens from me for the purpose of diagnostic testing as ordered above. I understand that samples will be tested by qualified laboratory personnel and that test results will be released to the ordering provider and other health care entities involved in my care. I acknowledge the following risks and conditions:

• Common risks include bruising, bleeding, infection at the venipuncture site, fainting, or pain.
• Test results may be used for clinical management and may be shared with my insurer for billing and utilization review when necessary.
• I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance upon it.

By signing below I consent to the laboratory performing the ordered tests, to release test results to the ordering provider and to my insurer as necessary for payment and quality assurance, and to the retention and appropriate disposal of specimens in accordance with applicable policies and laws.

HIPAA / Privacy Acknowledgment

I acknowledge that I have been offered or received a copy of the facility's Notice of Privacy Practices describing how my health information may be used and disclosed. I authorize the disclosure of my protected health information as necessary for treatment, payment, and healthcare operations related to the tests ordered on this form.

Patient may indicate additional restrictions on the release of results below. The laboratory and ordering provider will make reasonable efforts to honor such restrictions but may be required by law or payer policy to disclose certain information.

Ordering Provider / Billing Information

NPI Number:    Clinic/Facility:

Laboratory Use Only

Specimen ID:    Collected by (initials):

Received Date/Time:    Processing Notes:

Certifications and Acknowledgements

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that falsification of clinical information may impair proper interpretation of test results. I authorize assignment of benefits and direct payment to the laboratory for services rendered where applicable.

Sign Now