Medical Lab Report

MEDICAL LAB REPORT

Laboratory Information

Report ID:    Report Date:

Patient Information

Patient Name:

Date of Birth:    Sex:

Ordering Provider:    Provider NPI/ID:

Specimen Details

Specimen Type:    Collection Date:    Collection Time:

Tests Performed and Results

Test 1 Name:    Result:    Units/Reference:

Test 2 Name:    Result:    Units/Reference:

Additional Findings:

Certifications & Administrative Statements

This laboratory report has been prepared by duly qualified personnel and is provided for use by the ordering provider and the patient. The laboratory certifies that all tests reported herein were performed in accordance with applicable professional standards and the laboratory's established methods and quality control procedures.

Laboratory Director:    License/Accreditation No.:

WHEREAS / AGREEMENT RECITALS

WHEREAS, the Laboratory provides diagnostic testing, analysis and reporting services in accordance with accepted clinical laboratory practices; and

WHEREAS, the Ordering Provider or Client requires that such tests and related administrative services be performed under agreed terms; and

WHEREAS, the Laboratory and the Ordering Provider/Client desire to record the terms governing the provision of testing services, reporting, confidentiality, and payment.

Scope of Work

The Laboratory shall perform the diagnostic assays, specimen handling, quality control, result generation and reporting described herein and as ordered by the Ordering Provider. The Laboratory's responsibilities include sample accessioning, testing using validated methods, result verification by authorized personnel, and prompt delivery of results to the Ordering Provider in a confidential format.

Payment Terms

Fees for services shall be invoiced to the Ordering Provider or Client as indicated below. The Ordering Provider/Client is responsible for payment in accordance with the terms set forth.

Term and Termination

This Agreement shall commence on the Start Date and continue until the End Date unless earlier terminated in accordance with this section.

Start Date:    End Date:

Either party may terminate for material breach if the other party fails to cure such breach within the specified notice period. Termination does not relieve the Ordering Provider/Client of obligations to pay for services performed through the effective date of termination.

Confidentiality

The Laboratory and the Ordering Provider/Client shall each maintain the confidentiality of patient health information and proprietary business information in accordance with applicable legal and ethical obligations. Protected health information shall be used and disclosed only as necessary to perform the services described and as otherwise permitted or required by law. Each party shall implement and maintain administrative, physical and technical safeguards to protect confidential information.

Governing Law

This Agreement, including any dispute arising out of the performance of laboratory services and reporting of results, shall be governed by and construed in accordance with the laws of the State of without regard to its conflict of law principles.

Entire Agreement

This document, together with any appendices or attachments expressly incorporated herein, constitutes the entire agreement between the Laboratory and the Ordering Provider/Client with respect to the subject matter contained herein and supersedes all prior and contemporaneous agreements, representations and understandings, whether written or oral. No amendment or modification shall be effective unless in writing and signed by authorized representatives of both parties.

Acknowledgment

By signing below, the parties acknowledge receipt of this Medical Lab Report and agree that the terms set forth in the WHEREAS and Agreement sections govern the provision, reporting, use and payment for the laboratory services described in this report.

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