INFORMATION:

Self PayClient BillInsuranceMedicare/Medicaid

PATIENT INFORMATION:

ORDERING PHYSICIAN:

Physician’s Medical Necessity Notice: You should only order laboratory tests that are reasonable and medically necessary for the diagnosis and treatment of your patient. Upon request, you must be able to provide documentation to support the medical necessity of the laboratory tests marked on this test request form for Auspicious Laboratory to perform.

DIAGNOSIS CODE:

Advanced Beneficiary Notice (ABN): [For Medicare Patients Only] When laboratory tests are ordered for a Medicare patient that you believe will not be paid by Medicare, you must have the patient sign an Auspicious Laboratory ABN form signed and dated by the patient at the time of service. Otherwise, Auspicious Laboratory will charge the client for laboratory tests not covered by Medicare.

I certify that I have voluntarily provided a specimen for analytical testing. The information provided on this form and on the label affixed to thespecimen is accurate. I authorize Auspicious Laboratory Inc. to release the results of this testing to the treating physician or facility. I herebyinsurance benefits to be paid directly to Auspicious Laboratory Inc. for services I received. I acknowledge that Auspicious Laboratory Inc. may be an out-of-net work provider with my insurer. I am also aware that in some circumstances my insurer will send the payment directly to me. I agree to endorse the check and forward in to Auspicious Laboratory Inc. within 30 days of receipt. Failure to do so may result in my account being forwarded to Collections and to a Credit Bureau. I understand that Auspicious Laboratory, Inc may use my specimen and testing results, for research, development, and potential purposes, so long as the information has been properly deidentified p-ursuant to law.

PATIENT’S SIGNATURE :

SELECT TEXT (PANEL) REQUESTED WITH THIS PATIENT SAMPLE

DIAGNOSTIC CODES REQUIRED

Please make sure fill out the diagnostic codes at the top of this form.

The list below has been provided for your convenience. This is not an all-inclusive list and the ordering physician should precribe the diagnostic codes that best describe the reason for performing each test whether or not it appears in the list.

RESPIRATORY & COVID-19