Healthcare PAT Testing Form

HEALTHCARE PAT TESTING FORM

Patient Information

Date of Birth:   Gender: Male Female Other

Primary Phone:   Email:

Emergency Contact

Relationship:   Phone:

Insurance Information

Policy Number:   Group Number:

Medical History & Current Status

Bleeding disorder or platelet dysfunction    On anticoagulant therapy (e.g., warfarin, DOAC)    Pregnant or possibly pregnant

Test Order & Specimen Collection

Specimen Type: Blood Urine Swab Other

Fasting Status: Patient fasting Not fasting   Specimen Collection Date:   Time:

Consent for Testing and Release of Results

I authorize the collection of clinical specimens and performance of the tests listed above. I understand that specimens may be used for diagnostic purposes and that testing may include required confirmatory or supplemental assays. I consent to the release of my test results to the ordering provider and to authorized health care personnel involved in my care. I understand that certain tests may yield incidental findings and that I may be contacted regarding clinically significant results.

I acknowledge the following risks associated with specimen collection: brief pain at the collection site, bleeding, bruising, infection, fainting, or, rarely, more serious complications. I have had the opportunity to ask questions and they have been answered to my satisfaction. 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.

By signing below I consent to testing and to the release of results as described. I accept financial responsibility for services not covered or denied by my insurer.

Authorized Release of Results to Third Parties

If you wish to have results released to a spouse, family member, employer, or other third party, provide their information below. Results will be released only as authorized by you.

Relationship to Patient:   Phone:

Preferred Result Delivery Method: Phone call Mail Email Fax

Billing / Financial Responsibility

I authorize billing to the insurance identified above and direct payment of benefits to the facility when applicable. I understand that I am financially responsible for charges not covered by insurance, including deductibles, co-payments, and services denied as not medically necessary.

Laboratory Use Only

Accession / Lab ID:   Collector Name (printed):

Collector Initials:   Collection Notes:

Authorization Expiration

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

Acknowledgment and Patient Certification

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that withholding or providing inaccurate information may affect the interpretation of test results. I understand my rights concerning privacy and the release of my medical information and have been provided an opportunity to ask questions.

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