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I understand my signature Is required for each patient's test order. I understand that it Is my responsibility to determine the medical necessity of tests I have requested for the treatment and/or diagnosis of my patients. I agree to provide diagnosis codes, defined to the highest level of specificity, for each test that I request in order to confirm medical necessity and to enable the laboratory to bill effectively on my patient's behalf. Tests that are deemed medically unnecessary may result in a denial of payment and/or penalties. I understand that the laboratory will be billing third parties for the tests I ordered using CPT codes noted in the Annual Notice to Physicians. In the event that Insurance providers request documentation, I will provide signed written orders from the patient’s medical record to the requesting party within 72 hours.

The undersigned has read and understands this policy and is authorized to sign for the practice.


Payer Mix Analysis

In an effort to best serve your practice , it is imperative that we gain a full
understanding of your payer mix. Please list the top 15 insurance payers in
the financial class, a percentage of your billing that each payer represents,
and the volume per month.