Healthcare Laboratory Evaluation

HEALTHCARE LABORATORY EVALUATION

Patient Information

Date of Birth:   Gender: Male Female Other

Insurance & Billing

Ordering Provider / Facility

Provider Phone:   Provider Fax:

Specimen and Tests Requested

Date Collected:   Time Collected:   Collected By:

CBC (Complete Blood Count)   CMP / Basic Metabolic Panel   Lipid Panel   Hemoglobin A1c   Urinalysis   Microbiology / Culture   PCR / Molecular Assay   Serology / Antibody Testing  

Clinical History / Indication

Consent for Testing, Storage, and Release

By signing below, I, the undersigned patient or authorized representative, authorize the laboratory to perform the tests requested above. I acknowledge that:

1. Specimens may be retained, frozen, or otherwise stored as required for confirmatory testing, quality control, or medical necessity unless I have indicated otherwise.
2. The laboratory may perform additional or reflex testing as clinically indicated by the initial test results. Such additional testing will be performed in accordance with accepted clinical practice and laboratory policy.
3. Results will be reported to the ordering provider and to other persons or agencies as required by law. I authorize release of results to the ordering provider and to the emergency contact listed above unless I instruct otherwise below.
4. Testing may include assays that require specialized handling; improper specimen collection may invalidate results and may require recollection.

Release results to persons other than ordering provider (specify names and relationship):

I consent to the use of my de-identified specimen and test information for quality assurance and method validation unless I deny consent below.

I DO consent to de-identified specimen retention for validation and quality assurance.
I DO NOT consent to de-identified specimen retention for research or validation.

Genetic testing: I acknowledge that certain tests may reveal genetic information. If genetic testing is ordered, I have been informed of the need for separate specific consent and counseling when required.

I acknowledge notification regarding genetic testing and understand separate consent may be required.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the laboratory's privacy practices and understand that information about my health and test results will be used and disclosed for treatment, payment, and healthcare operations as permitted under applicable privacy law.

I acknowledge that I have received or been offered the laboratory's privacy notice.

Limitations, Liability, and Billing

The laboratory will exercise reasonable care in performance of testing. Test results are interpreted in the context of clinical findings; the laboratory is not responsible for medical decisions based on results. The laboratory's liability for any error is limited to correction or repetition of the test at its expense where error is confirmed.

I understand that charges for laboratory services may be billed to my insurance and that I am financially responsible for amounts not covered by insurance, including collection failures or insufficient documentation. By signing below I authorize assignment of benefits to the laboratory where applicable.

I authorize assignment of insurance benefits to the laboratory and direct payment for services rendered.

Authorization Duration

This authorization for testing, specimen retention, and release remains valid until:   or until revoked in writing by the undersigned.

Specimen Handling and Recollection

If a specimen is unacceptable (improper container, inadequate volume, mislabeled, or compromised), the laboratory will notify the ordering provider and recollection may be required. Urgent results will be communicated by telephone to the ordering provider as indicated.

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