Healthcare Medical Screen Request

Healthcare Medical Screen Request

Requesting Provider/Facility certifies that the medical screening requested below is necessary for assessment, clearance, or diagnostic purposes. By submitting this request, Requesting Provider/Facility authorizes the recipient clinical facility to perform the examinations and tests indicated and to release results as stated herein. This request includes authorization for the use and disclosure of protected health information to the Requesting Provider/Facility and any payer required for billing and coverage determination in accordance with applicable privacy laws.

Requesting Provider / Facility

Patient Information

Patient Name:    Date of Birth:

Emergency Contact

Insurance Information

Medical History

Is the patient pregnant? Yes No

Requested Screening / Tests

Please select all requested services. Tests not marked will not be routinely performed unless clinically indicated.

Physical examination
Blood work / basic metabolic panel / CBC
Urinalysis
Urine / saliva drug screen
Chest X-ray
Electrocardiogram (ECG)
Tuberculosis testing (PPD or IGRA)
Immunization record review / immunizations
Other (specify below)

Authorization and Consent

I authorize and consent to the performance of the examinations and tests indicated above. I understand that the scope of the screening may include but is not limited to physical examination, collection of blood, urine, and other specimens, imaging studies, and diagnostic testing. I acknowledge that specimens may be retained for quality control or confirmatory testing as permitted by law.

I authorize the release of the results of these examinations, tests, and any relevant medical records to the Requesting Provider/Facility and to insurers or payers for purposes of payment and utilization review. I understand that disclosure will be limited to the information necessary to fulfill the request and that my health information will be handled in accordance with applicable privacy laws.

I acknowledge that I may refuse any portion of the requested screening; refusal may limit the ability of the Requesting Provider/Facility to make employment, clearance, or treatment decisions. I understand that I may revoke this authorization by providing a signed written notice to the treating facility, except to the extent actions have already been taken in reliance on this authorization. I accept financial responsibility for services not covered by insurance or otherwise payable by me or my responsible party.

Potential risks and common side effects have been explained, including local pain, bruising, infection at specimen sites, allergic reactions, and other risks as applicable to the indicated procedures. If additional or unexpected findings arise during screening, the facility will inform the Requesting Provider/Facility and may take appropriate clinical steps as permitted by law.

Privacy Acknowledgment (HIPAA)

I acknowledge that I have been informed of the clinic's privacy practices and that my protected health information may be used and disclosed as described above for treatment, payment, and healthcare operations. I understand that the clinic will take reasonable steps to protect my confidential information.

I acknowledge and consent to the use and disclosure of my health information as described above.

Authorization Expiration

This authorization will expire on: . If no date is provided, this authorization will expire one (1) year from the date of signature.

Billing and Payment Responsibility

By signing this form, I authorize billing to the insurance identified above. I understand that I am responsible for payment of charges not covered by insurance and for any co-payments, deductibles, or non-covered services. I authorize release of information necessary to process claims. Disputes regarding charges will be addressed according to the clinic's financial policies.

Additional Clinical Notes (for receiving facility)

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