I certify the patient (or authorized representative on the patient’s behalf) has given informed consent (which includes written informed consent or
written authorization when required by law) to have this testing performed, and the informed consent obtained from the patient meets the
requirements of applicable law. I agree to provide the associated lab, or its designee, any and all additional information reasonably required and
obtained for this testing to be performed and billed; I have informed the patient there is no guarantee of insurance coverage or payment. Any
notification of results to patients will be documented in the medical record, if performed.
❑ This test is medically necessary based on screening.
Healthcare Provider Printed Name:___________________NPI: _____________
Healthcare Provider Signature: ___________________ Date: ______________