1.  The provider(s) requests the creation of a custom test panel that includes the tests listed below on this acknowledgement form starting on page 3 under "Custom Panel Test Selection"
2. The provider(s) understands that any or all tests can be individually ordered on a laboratory requisition form at any time, without ordering a custom or comprehensive panel
3. The provider(s) agrees to order selected tests after having determined that each individual test component of the panel is medically necessary for the affiliated patient(s)
4. When ordering tests for which Medicare reimbursement will be sought, the provider(s) understands that only tests which are medically necessary for each patient should be ordered, and that using a custom test panel may result in the ordering of tests which Medicare or other federally funded healthcare programs may deny payment
5. The provider(s) knows of the office of Inspector General's position that a person who orders or influences the ordering of non-medically necessary test which Medicare and Medicaid reimbursement is claimed may be subjected to civil penalties under the False Claims Act
6. The provider(s) acknowledge that there is no obligation or any restrictions regarding the ordering of testing set forth in the custom order panel
7. It is hereby certified that the treating provider(s) shall review the volume frequency and the duration of testing and order laboratory testing accordingly and in accordance with clinical indication and medical necessity
8. If the custom test panel is selected and ordered, the signatories hereto verify that the custom test panel checked below accurately reflects the tests intended to be ordered.

I authorize MedScan Laboratory Inc. to follow the protocol listed above when conducting tests on patient samples sent to their lab from my clinic(s) unless I instruct otherwise on a signed requisition form. I believe this protocol to be medically necessary and reasonable for my patients, and I acknowledge that MedScan Laboratory Inc. has provided me with information regarding its policies and guidelines for qualitative and confirmatory drug screening. The signatories hereto understand there may be applicable National Coverage Determinations and Local Coverage Determinations for Clinical Laboratory Qualitative and Quantitative Drug Testing and Drugs of Abuse Testing. The start date for the ordering of this custom test panel is {date} and will continue until MedScan Laboratory is notified to remove the custom panel or upon the creation of a new custom test panel order.

My signature below is my express representation and warranty that I have created documentation in my official patient record on or prior to the date hereof that is sufficient to demonstrate the medical necessity of all tests ordered. My failure to do so or to have done so shall result in MedScan Laboratory Inc. being able to claim reimbursement from me for any payments subsequently denied, reduced, or recouped by any third-party payor for the lab tests requisitioned hereby.