Consent Form for Uninsured Patients Undergoing Lab Tests

Consent Form for Uninsured Patients Undergoing Lab Tests
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Consent for Lab Testing and Billing Information

Our office strives to provide the best care possible, including necessary laboratory tests. For patients without insurance, please review and acknowledge the following information regarding your lab tests and billing:

1. Lab Testing Provider:

·         Your lab tests will be sent to Labcorp for processing and analysis.

2. Billing Information:

·         As you do not have insurance, you will receive a bill directly from Labcorp for the lab tests performed.

3. Labcorp Coupon:

·         Our office will provide you with a Labcorp coupon upon receiving the bill. This coupon will allow you to pay the bill at a reduced price.

4. Patient Acknowledgment:

·         I acknowledge that I have been informed that I will receive a bill from Labcorp for the lab tests conducted.

·         I understand that I am responsible for paying this bill.

·         I have been advised that the office will provide me with a Labcorp coupon to help reduce the cost of the bill.
Parent/Guardian Signature:

I, the undersigned, have read and fully understand the above information. I consent to the lab tests and acknowledge my financial responsibility.
Parent/Guardian Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: