I agree to the following:
Lab results are reported directly to me in the manner chosen below. I understand that Advanced Practice Clinic will report the results directly to me, my healthcare provider, or any other party that I request. I authorize that such disclosure may be made by fax, email, or direct-pickup. I understand and agree that the services provided by Advanced Practice Clinic and the test results from the lab will be maintained as confidential, protected health information by Advanced Practice Clinic as required by federal and state law.
It is my responsibility to consult my own medical provider for interpretation, analysis, evaluation, and explanation of my test results.
I understand that neither Advanced Practice Clinic, nor it's medical providers and/or staff members will analyze, evaluate, critique, review or otherwise interpret the results of said tests.
I agree that Advanced Practice Clinic, it's medical providers and/or other staff members shall not be liable for any claims, including, but not limited to, any claim arising out of a related to, inaccurate, un-interpreted, misinterpreted or results not received and do hereby expressly forever release and dicharge all claims, demands, injuries, damage, actions or courses of action.
I certify that I will not seek to be reimbursed by Medicare, Tricare, or any other government insurer/payor. I agree that I am personally financially responsible for payment of fees for all tests ordered and collected by Advanced Practice Clinic at my request.
I understand that the blood and/or urine or other test samples performed at Advanced Practice Clinic are done at my request to be screened through either blood and/or urine or other specimen testing. I further understand that a physician or practitioner of Advanced Practice Clinic who is licensed under state law to order such testing will do so. I also understand that Advanced Practice Clinic is a lab collection facility and that the actual testing will be performed by a third party laboratory, certified to perform such testing.
I have had an opportunity to have any questions answered that I may have regarding the aforementioned statements and/or my rights to privacy by a staff member of Advanced Practice Clinic. I understand that I may request a copy of the Notice of Privacy Practices from Advanced Practice Clinic or I may choose not to receive a copy.