Intake Form

Customer Information

Contact Name*

Date of Birth*

Contact Phone*

Fax

Contact Email*

Address*

City*

State*

Zip*

Allergy Information

Latex

Alcohol

Betadine

Other

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Please Specify:*

Your Tests or Panels*

Preferred Method of Receiving Results*

U.S. Mail

Pick-Up

Phone

Fax

Mailing Address*

City*

State*

Zip*

Email Results To:*

Phone:*

Fax Results To:*

Customer Information Release & Consent

I understand that test results reported by ANY LAB TEST NOW/ANY TEST PC will be reported directly to me, in the manner chosen below.

I further understand that it is my responsibility to consult my own medical doctor for interpretation, analysis, evaluation, and explanation of my test results. I release the ordering physician from any duty or professional obligation to interpret the results, which would ordinarily be the standard of care. I understand that neither ANY LAB TEST NOW/ANY TEST PC nor its ordering physician will analyze, evaluate, critique or otherwise interpret the results of said tests. I agree that ANY LAB TEST NOW/ANY TEST PC, its officers, shareholders, directors, employed physicians, or its other agent or employee shall not be liable for any claims including, but not limited to, any claim arising out of or related to, inaccurate, uninterrupted, misinterpreted or results not received and do hereby expressly forever release and discharge all claims, demands, injuries, damage, actions or causes of action.

I certify that I will not seek to be reimbursed by Medicare, Medicaid, Tricare or any other government insurer/payor. I agree that I am personally financially responsible for payment of fees for all tests ordered and collected by ANY LAB TEST NOW/ANY TEST PC at my request.

I understand that the laboratory tests performed at ANY LAB TEST NOW/ANY TEST PC are done at my request. I further understand that an ANY LAB TEST NOW physician who is lisenced under state law to order such testing will do so. I also understand that ANY LAB TEST NOW/ANY TEST PC is a collection facility and that the actual testing will be performed by a third party laboratory, certified to perform such testing on the specimens collected by ANY LAB TEST NOW/ANY TEST PC. I understand and agree that ANY LAB TEST NOW/ANY TEST PC will report the results of the testing directly to me, my physician, or any health professional I request. I consent and authorize that such disclosure may be made by fax, by mail or by direct pick-up. If I wish my email used only for test results, I will specifically make that request known to ANY LAB TEST NOW/ANY TEST PC personnel. I understand and agree that the services provided by ANY LAB TEST NOW/ANY TEST PC and the test results from the lab will be maintained as confidential, protected health information by NY LAB TEST NOW/ANY TEST PC as required by federal and state law.

I understand that the test results may become part of my medical record. I also understand that an insurance company may discover the results of this testing by obtaining a copy of my medical record in accordance with the terms of my insurance policy(ies). I hereby consent to the release of my laboratory test results by ANY LAB TEST NOW/ANY TEST PC to me in the manner I have chosen below and my physician or any other healthcare provider I designate. I understand that my test results will only be provided to other third parties upon my express consent.

All of the above has been discussed with me and I have had an opportunity to have any questions answered that I may have regarding my rights to privacy by an employee of ANY LAB TEST NOW/ANY TEST PC. I have received a copy of Notice of Privacy Practices, as required by HIPAA from ANY LAB TEST NOW/ ANY TEST PC or I have chosen not to receive a copy.

I have read and agreed to all the above terms.

Applicant Name*

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