Healthcare CBC CMP Form

HEALTHCARE CBC CMP FORM

Patient Information

Date of Birth:    Gender:

Home Phone:    Mobile:

Relationship:    Phone:

Insurance & Billing

Primary Insurance:

Policy / ID Number:    Group Number:

Clinical / Medical History

Requested Tests

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

Specimen Collection

Collection Date:    Collection Time:

Specimen Type:    Venous blood    Capillary (fingerstick)    Serum separator tube (SST)    Heparin tube (green)

Fasting Status: Fasting    Non-fasting    Hours fasted (if applicable):

Ordering Provider

NPI / License #:    Office Phone:

Consent and Authorizations

I authorize the collection of blood and performance of the tests indicated above. I acknowledge that the tests ordered are medically necessary as determined by the ordering provider. I understand the risks associated with phlebotomy, including bruising, infection, fainting, and hematoma formation. By signing, I consent to the drawing of blood and laboratory testing described herein.

I authorize disclosure of laboratory findings to the ordering provider and other healthcare personnel involved in my care. I hereby assign and authorize payment of insurance benefits to the laboratory or facility performing the tests. I agree to be financially responsible for services not covered by insurance, subject to applicable law and facility billing policy.

I have the right to refuse any test or procedure. I understand I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on this authorization. This authorization expires on: . Revocation must be submitted in writing to the facility where samples are collected.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the facility's privacy practices and understand that my protected health information may be used or disclosed for purposes of treatment, payment, and healthcare operations as described in that notice. I authorize use and disclosure of my protected health information as necessary to process claims, consult with specialists, and perform quality assurance related to laboratory testing.

Release of Results To: Ordering Provider (default)    Additional Recipient (name):

Patient acknowledges the above by checking: I acknowledge I received privacy practices and consent to disclosures as described.

Specimen Handling & Results

Specimens will be processed in accordance with standard laboratory protocols. Results will be reported to the ordering provider and are part of the medical record. The facility is authorized to retain, discard, or anonymize residual specimens according to its policy and applicable law unless additional written restrictions are provided at the time of collection.

Additional Information

If signing as a legal guardian or personal representative, provide relationship to patient and legal authority below.

Sign Now