Prepaid General Health Fair Lab Testing Form

Prepaid General Health Fair Lab Testing Form - Blue Hill City Office

Please fill the entire form below to register. Make sure to hit submit at the bottom after choosing a date and time. You will receive an email confirmation.
Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender
Phone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Primary care provider (It is your responsibility to forward results to your provider.)
Which tests would you like to order. Check all that apply.

Health Fair Panel (CBC, CMP, Lipids, TSH) $30PSA Screen (males age 50 and over) $10Testosterone, total (TESTTTL, males) $15Free T4 (FREET4) $10Glyco, A1C $15Vitamin D $15Vitamin B12 $15Iron Profile (IRNPROF) $10Ferritin (FERRITN) $20Microalbumin, urine (MICRALB) - early signs of kidney disease $10
My results

I request and authorize Mary Lanning Healthcare to send results to the MLH electronic health record (EPIC/ONECHART/MYCHART).I request results be emailed to me with encryption. (PLEASE NOTE: Encrypted emails cannot be read by a third party but they require extra steps to open. Instructions on how to open these encrypted emails can beprovided upon request.)I request results be emailed to me unencrypted. (PLEASE NOTE: If selecting unencrypted email, you accept and understand the risk in receiving your PHI this way and that it may be read by a third party.)I request the results be sent to my physical address.
By signing below, I acknowledge the following:
- I release Mary Lanning Healthcare from all claims, demands and assertions of liability engendered by myself or my representatives, arising from or based upon Mary Lanning Healthcare or its activities (including tests, omissions, errors, disclosures or nondisclosures) which may arise from data obtained as required.
- I hereby request and authorize Mary Lanning Healthcare for venipuncture as required for the purpose of performing blood test determination.
- I understand that my lab results will not be sent by Mary Lanning Healthcare to my primary care physician.
- I agree to Personal Disclores of my lab resuts to Electronic Health Record (EPIC), or to my email, if either was requested above.
- I have prepaid and I hereby restruct this service from being filed with my insurance company for payment by me or by Mary Lanning Healthcare.
Signature (Draw your name with your mouse.):

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Payment type (due upon arrival):

CashCheck
Please do not sign the "Decline Prepaid" box unless you want us to submit the costs of this bloodwork to your insurance, rather than paying with cash or check. Just continue on to selecting an appointment date and time. Don't forget to hit submit at the bottom of the form.
Decline Prepaid: I acknowledge that I have been informed of the special prepaid process and I hereby decline to participate in this offer. I request that my service today be billed at regular charges to my insurance company and will require a physician order.
Insurance company (if applicable):
Signature (Draw your name with your mouse.):

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Prepaid General Health Fair Lab Testing Form - Blue Hill City Office