Healthcare Patient Castle Biosciences Form

Healthcare Patient Castle Biosciences Form

Patient Information

Patient Name:

Date of Birth:    Gender: Male   Female   Other (specify):

Insurance Information

Ordering Provider & Facility

Specimen and Test Information

Specimen Type:    Collection Date:

Medical History

Chronic Conditions (check all that apply):   Diabetes   Hypertension   Heart disease   Other:

Authorization for Testing and Release of Health Information

I authorize the ordering clinician and the facility named above to release my specimen and relevant protected health information to Castle Biosciences and its authorized agents for the purpose of performing the requested diagnostic test(s), interpretation, and reporting results to my clinician. This authorization includes release of pathology reports, clinical history, and other medical records necessary to perform and interpret the test.

I understand that the results may affect clinical decision-making. I further authorize Castle Biosciences to disclose test results to the ordering clinician, treating providers, and my insurance carrier as necessary for treatment and payment. I understand that once disclosed, my information may be subject to redisclosure by the recipient and may no longer be protected by federal privacy rules.

Risks and Limitations: I understand that no test is 100% accurate. Results may be indeterminate, require additional testing, or be of uncertain clinical significance. The testing laboratory will use established laboratory methods; however, experimental or investigational findings may be reported if they are believed to be clinically relevant. There is a minimal risk that my specimen or data could be re-identified if used for research or quality assurance with identifiers removed.

Right to Revoke: I may revoke this authorization in writing at any time by delivering a written notice to the ordering clinician or to Castle Biosciences. Revocation will not affect actions taken in reliance on this authorization prior to receipt of the revocation. To the extent the test has already been performed or results shared, those actions cannot be undone.

Optional Research Use: I consent to the retention of leftover specimen and de-identified data for internal quality improvement and research purposes: Yes   No

Financial Responsibility and Assignment

I authorize assignment of benefits to Castle Biosciences for services rendered. I understand that my insurance will be billed, but I remain financially responsible for any portion not covered by my insurance, including co-payments, deductibles, and non-covered services. If my insurance denies payment, I agree to be responsible for payment in full.

If applicable, please indicate payer preference for billing: Bill insurance first   Bill patient directly first

HIPAA Privacy Acknowledgment

I acknowledge that I have been provided with, or offered, a notice of privacy practices describing how my protected health information may be used and disclosed. I understand that I may request restrictions on certain uses and disclosures, and that such requests must be made in writing to the ordering clinician or Castle Biosciences.

I acknowledge and consent to the transmission of my protected health information via secure electronic methods for the purposes described above.

Acknowledgment: I acknowledge receipt of this notice and consent to the uses and disclosures described herein.

Authorization Expiration and Revocation

This authorization will expire on: unless an earlier date is specified by my written revocation. If no date is provided, this authorization expires one year from the date signed.

Certification

By signing below I certify that the information provided on this form is true and correct to the best of my knowledge. I authorize the release of my specimen and health information as described above, and I consent to testing and reporting. I understand that I may request a copy of this signed authorization.

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