I understand that responsibility for payment for services provided by MedTech Laboratory Services, LLC for myself or my dependents is my personal responsibility entirely, whether have healthcare insurance coverage or not. I understand that if I have healthcare insurance it is my personal responsibility to verify coverage and/or benefits regarding all services provided by MedTech Laboratory Ser- LLC vices,priortoreceivingservices. I agree that I am responsible to pay 100% of the provider's actual charges. In addition, I agree to pay interest of 1% monthly (12% annually) and a one-time delin- quency fee equal to 25% of the past due balance. I also agree to pay court costs and attorney fees as may be required to effect collection of any past due balance.
The Information provided on this form and on the specimen collection device is accurate. I acknowledge that Medtech Laboratory Services, LLC may be an out of network provider with my insurer. I am alsothatin cases awaresomemy insurer may send the payment directly to me; if that happens, I agree to endorse the check to Medtech Laboratory Services within 5 days. I understand that Medtech Laboratory Services, LLC may use my specimen and any testing performed on that specimen for research development and potential publication purposes as long as the information has been properly de- identified pursuant to applicable law.