The ordering authorized Health Care Provider understands and hereby acknowledges that (a) the tests ordered are medically necessary for this particular patient, given the patient’s clinical condition, and have been recorded in the patient’s clinical file and that the Health Care Provider is responsible for assigning and providing specific ICD-10 code(s) to support the medical necessity of any and all laboratory tests; and (b) the Health Care Provider must make a determination that medical necessity exists each time a specimen is submitted.

By my signature below I voluntarily consent to the collection and testing of my specimen and the release of the testing results to the ordering physician/facility, however such results shall be used solely for clinical diagnostic/treatment purposes only and shall not be used for any forensic purposes related to my employment or other legal or administrative purposes. The specimen identified by this form is my own, is fresh, and is unadulterated. I authorize Advanced Diagnostic Laboratory to bill my insurance directly for services I receive and acknowledge thatAdvanced Diagnostic Laboratory may be an out-of-network provider with my insurance. I am aware that in some instances my provider may send payment directly to me. In such instances I agree to endorse the check and forward it to Advanced Diagnostic Laboratory within 30 days. Failure to do so may result in my account being turned over for collection and the delinquency reported to credit rating agencies. If the self-pay box is checked I agree to be financially responsible for the laboratory fees incurred with regards to the above ordered tests.