Insurance billing — pharmacogenomic testing order form

I, the undersigned provider, attest that I am the ordering physician and treating clinician for the patient identified on this requisition. I confirm that the medical necessity for each test ordered is documented in the patient’s record, and I will provide supporting documentation within 72 hours when requested. I attest that all tests ordered are medically necessary, individualized to the patient’s condition, clinically appropriate in frequency, and will guide patient care decisions. I have attached all prescribed medications, over-the-counter drugs, and herbal products that may impact test results. I certify that all information provided, including ICD-10 codes, is accurate and complies with applicable payer medical necessity policies. I confirm that the patient (or their legal guardian) has provided informed consent for this genetic test, and a record of this consent is maintained or attached. I authorize the laboratory to bill the patient and/or their insurance for the ordered tests. I acknowledge that testing will be performed in compliance with all applicable healthcare regulations, including HIPAA and CLIA, as required.

I voluntarily consent to the collection and testing of my specimen and authorize the laboratory to perform the ordered test and release my test results to the ordering clinician. If I have provided my insurance information, I authorize the performing lab to bill my insurance directly, receive payment on my behalf, and act as my designated representative to appeal any denial of health benefits. I understand that I am responsible for any amounts not covered by my insurance, including deductibles, copayments, and coinsurance, and for forwarding any payments I may receive from my insurer to the performing lab for services rendered. I confirm that I have an ongoing provider-patient relationship with the ordering provider and that test results will be used in the provision of my healthcare.