I understand that it is my option to select Specific Tests and/or Panels on a Test Requisition Form. Only those tests indicated on the Test Requisition Form will be tested, including reflex testing as documented on the Test Requisition Form. I understand that it is my responsibility to determine the medical necessity of the tests that I have requested for the treatment and/or diagnosis of my patients. Tests that are deemed medically unnecessary may result in a denial of payment and/or penalties.
By signing this document, I acknowledge that I authorize Innovative Genomics and its affiliates to perform testing on my patients from my practice as directed by the individual Test Requisition Forms.
I understand that Innovative Genomics and its affiliates will be billing third parties for the tests I order. In the event that an insurance providers request documentation, I will provide signed written orders from the patient's medical records to the requesting party within 72 hours.