TruChoice Diagnostics Self-Pay Lab Work DRAFT (as of 8.8.2023)

TruChoice Diagnostics Pre-Registration
Name:*

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
E-Mail:
example@example.com
Date of Birth:*

MonthDayYear
MM/DD/YYYY
MALEFEMALE
Primary Care Physician (PCP):*
Do you want a copy of your lab report sent to your PCP?*

YesNo
Will you be fasting? (12hrs Recommended)

YesNo

ATTENDING PROVIDER AGREEMENT

TruChoice Diagnostics, LLC
Consent for treatment/payment:

      This is to certify that I consent to and authorize the performance of specimen collection and analysis of the chosen laboratory panels.

      TruChoice Diagnostics, LLC cannot perform laboratory testing for patients who do not have a Primary Care Physician; A Primary Care Physician must be provided upon registration in the event that the Attending Provider who your labs are ordered under needs to reach them in regards to any critical results. I understand that the Attending Provider will not follow up with me or my Primary Care Physician regarding my lab results unless there is a critical value and it is my responsibility to obtain my results and seek interpretation, counsel, or treatment.

      I agree to take full financial responsibility for the cost of the tests that I request and that payment/insurance must be rendered prior to specimen collection.
Signature:*

Clear
Signature Date:

MonthDayYear
Date

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

To receive a copy of your results please review and sign below:
1. I understand that this authorization will expire 1 year from the signature date.
2. I understand that I may revoke this authorization prior to the release of results.
3. I understand that I can refuse to sign this authorization and my service or care will not be affected.
4. I may inspect or copy any information used or disclosed under this agreement.
5. I authorize the release of medical information to other physicians and/or facilities involved in my health care.
6. I understand that if the person or organization that received the information is not a healthcare provider, the information described above may be redisclosed and would no longer be protected under these regulations.
Patient's First Name:
Patient's Last Name:
Patient's DOB:

MonthDayYear
Date of Birth
I voluntarily authorize the disclosure of information from my health record to myself and other entities involved in my care.
Signature:*

Clear
Signature Date:

MonthDayYear
Date
You have the right to inspect and copy your own health care information, and that of an individual of whom you are a legal guardian or next of kin. Please provide the necessary information to access your lab results or simply decline this service below.
SELECT HOW YOU WOULD LIKE TO ACCESS YOUR RESULTS

Select one of the options below:
PATIENT PORTAL ACCESS ->

View all of your lab results online through our secure patient portal
PATIENT PORTAL ACCESS ->

View all of your lab results online through our secure patient portal
PATIENT PORTAL ACCESS
Provide your E-Mail address to receive a registration code to view all of your lab results online through our secure patient portal
MAIL RESULTS ->

Receive results via mail at your address on file within 2 weeks of result completion. *This service costs $2.00 as the time of specimen collection*
DECLINE ACCESS ->

I decline access to my own lab results
MAIL RESULTS ->

Receive results via mail at your address on file within 2 weeks of result completion. *This service costs $2.00 as the time of specimen collection*
DECLINE ACCESS ->

I decline access to my own lab results
I am requesting my own informationI am next of kin requesting on behalf of the patient and our relationship is:
Should be Empty:

TruChoice Diagnostics Pre-Registration

ATTENDING PROVIDER AGREEMENT

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

I voluntarily authorize the disclosure of information from my health record to myself and other entities involved in my care.

SELECT HOW YOU WOULD LIKE TO ACCESS YOUR RESULTS