Healthcare Labcorp Patient Consent Form

HEALTHCARE LABCORP PATIENT CONSENT FORM

Patient Name:   Date of Birth:

Patient Information

Male Female Other Prefer not to disclose

Insurance & Billing

Medical History

Pregnant or possibly pregnant? Yes No Unknown

Specimen Collection & Testing Consent

I authorize Labcorp and its representatives to collect specimens (blood, urine, tissue, or other) and perform laboratory testing as ordered by my healthcare provider. I understand specimens may be tested by Labcorp or its validated subcontractors as necessary to complete ordered tests.

Purpose of testing and uses of results include: clinical diagnosis, treatment planning, public health reporting as required by law, quality control, and as otherwise authorized by me. I grant permission for results to be released to the ordering provider, other treating providers, and, when necessary for payment, to my insurer.

Risks and complications associated with specimen collection may include, but are not limited to, temporary pain, bruising, bleeding, infection at the collection site, fainting, and nerve injury in rare cases. I acknowledge that no guarantees have been made to me regarding the outcome of any testing.

Alternatives to testing and consequences of refusal were explained to me by the ordering provider. I understand that refusing testing may affect clinical diagnosis and treatment options.

I consent to the retention and limited use of residual specimens for internal quality assurance and method validation unless I indicate otherwise below.

Do you authorize storage/use of residual specimen for de-identified research or validation? Yes No

HIPAA & Privacy Acknowledgment

I acknowledge receipt of a notice describing how Labcorp may use and disclose my protected health information for treatment, payment, and healthcare operations. I understand that additional disclosures may be made as required by law. I authorize Labcorp to use and disclose my health information as necessary to carry out the services described in this consent.

I consent to being contacted by Labcorp or its agents regarding appointments, test results, billing, or administrative matters at the phone numbers or email addresses I have provided, including by automated calls or text messages. I understand message and data rates may apply.

I understand I may revoke this authorization in writing at any time except to the extent that Labcorp or others have already taken action in reliance on this consent.

Financial Responsibility & Assignment

I assign benefits to Labcorp for laboratory services and understand I am responsible for charges not covered by insurance, including copayments, deductibles, and non-covered services. I authorize my insurer to pay benefits directly to Labcorp for services rendered.

Patient Certification

By signing below I certify that the information I have provided on this form is true and complete to the best of my knowledge. I have read and understand this consent, I have had the opportunity to ask questions, and those questions have been answered to my satisfaction. I authorize the collection, testing, and release of my specimen(s) as described above and accept financial responsibility as stated.

Sign Now