Note: All information with a red asterisk ( * ) must be completed
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 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.
For non-touch screen devices, the patient needs to type their full name below, and provide a secondary identifier.
By selecting the Add Signature button, I attest that I approve of this digital signature
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 Express Gene Molecular Diagnostics Laboratory to bill my insurance directly for services I receive and acknowledge that Express Gene Molecular Diagnostics Laboratory may be an out-of-network provider with my insurance. I am aware that in some instances my insurer may send payment directly to me. In such instances I agree to endorse the check and forward it to Express Gene Molecular Diagnostics 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.
Specific Site Analysis
Positive Control Not Available
Positive Control Sent/To Be Sent
Do not include BRCA1/2 sequencing results for this multi-gene panel order due to previous negative testing for this patient through another diagnostic laboratory. PLEASE NOTE: a copy of the previous negative BRCA1/2 report MUST be included with the test requisition form for BRCA1/2 sequencing results to be excluded from the final Aeon Clinical Laboratories report. In addition, clinically significant BRCA1/2 variants(i.e.those classified as “pathogenic” or “likely pathogenic”) are always reported.
Physician Signature / Date
Patient Signature / Date
*BRCA1 and BRCA2 Somatic testing also available