Medical Specimen Form

MEDICAL SPECIMEN COLLECTION AND TRANSFER AGREEMENT

WHEREAS

WHEREAS, Provider Name: and Laboratory Name: (collectively, the "Parties") desire to document the terms under which biological specimens will be collected, transported, tested and transferred;

WHEREAS, Provider performs patient care and specimen collection and Laboratory performs diagnostic testing and reporting, and the Parties wish to set forth responsibilities, chain-of-custody procedures, payment terms and confidentiality obligations applicable to specimens submitted under this Agreement.

1. Patient & Specimen Identification

Date of Birth:    Sex:

2. Specimen Collection Details

Specimen Type:    Subtype / Site:

Collection Date:    Collection Time:    Collector Name:

3. Handling, Packaging & Preservation

Container Type:    Volume/Amount:

Preservation / Transport Conditions: Ambient Refrigerated (2–8°C) Frozen (≤ -20°C) On Ice

4. Chain of Custody & Transfer Log

Collected By (printed):    Time Collected:

Transferred To (courier / person):    Time Transferred:

Received by Laboratory (printed):    Time Received:

5. Payment Terms

Agreed Fee per Specimen/Test:    Billing Party: Provider Patient Laboratory

Late Payment Fee (monthly):

Payment Clause:

Laboratory shall invoice Provider in accordance with the Payment Schedule. Provider shall pay undisputed invoices within the agreed net terms. Disputed amounts shall be identified in writing and supported by documentation; undisputed portions remain payable. Late payments shall accrue interest as set forth above and Provider shall reimburse reasonable collection costs and attorneys' fees for overdue balances.

6. Scope of Work

7. Term and Termination

Agreement Start Date:    Agreement End Date (if any):

Either Party may terminate this Agreement for convenience upon written notice to the other Party provided no fewer than days' prior written notice. Termination for material breach may be immediate following failure to cure within 15 days after written notice of breach.

8. Confidentiality

Each Party shall maintain as confidential all Protected Health Information and any proprietary technical or business information received from the other Party in connection with specimen handling and testing. Confidential information shall be used solely for performance of this Agreement. Disclosure is permitted only as necessary for treatment, billing, regulatory reporting, or as required by law, provided the disclosing Party gives prompt notice when permissible and the receiving Party limits disclosure to the minimum required.

9. Compliance, Liability and Indemnification

Each Party shall comply with applicable laws, regulations and professional standards governing specimen collection, transport, testing and patient privacy. Laboratory's liability for claims arising out of testing or reporting shall be limited to direct damages and not exceed fees paid for the specific service at issue. Each Party shall indemnify and hold the other harmless from claims arising from its own negligence or willful misconduct.

10. Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of: without regard to conflict of laws principles.

11. Entire Agreement

This Agreement, together with specimen submission records and test requisitions executed by the Parties, constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous understandings and agreements, whether oral or written. Any amendment must be in writing and signed by authorized representatives of both Parties.

12. Collector Certification

I certify that the specimen identified above was collected in accordance with applicable standards and that the patient identification and labeling are accurate to the best of my knowledge.

Collector Printed Name:    Collector Role/ID:    Collection Record Number:

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