CONSENT TO SCHEDULE DIAGNOSTIC TESTS

Please review the following:
- REOH will order diagnostic studies or screening tests to determine if there are any medically related explanations for continued symptoms. REOH will arrange pre-authorization of payment for the studies, scheduling of the appointment(s), and tracking results. The party managing your claim will pay for the cost of the diagnostic studies and you are not responsible for payment of any kind. You authorize REOH to order diagnostic studies or screening tests for you.
- You will be notified of the diagnostic test appointment(s) by mail, telephone, and/or email. You authorize REOH to contact you regarding diagnostic tests via the phone number or email you have provided. You authorize REOH to leave a voicemail message regarding diagnostic tests.
- REOH will not contact you regarding the results, except in situations where, in our professional judgment, a condition posing an imminent danger to your physical or mental well-being is present. REOH’s final report will include a summary of the test results and will be sent with the actual test results to the party managing your claim. Health care professionals involved in your medical care will not receive results from diagnostic studies but can request these findings from the party who requested the appointment.
- This online form is fully HIPAA compliant and secure.
I have read and understand the above statement

Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your name

First NameLast Name
Phone number where REOH can contact you/leave voicemails regarding diagnostic tests
Format: (000) 000-0000.
E-mail where REOH can contact you regarding diagnostic test
example@example.com
Mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Last four digits of your social security number
I understand that I may revoke this consent at any time by providing REOH with a written request. In one year from the date above, this consent will automatically expire regardless of my express revocation. Please use your mouse to sign below.
If you have signed as a guardian on behalf of the injured worker, please indicate relationship.
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