This spicemen was provided voluntarily and I autorize the laboratory to process, bill and provide results, I authorize the release to my insurance carrier of any medical information necessary to process this claim, and I authorize payment of medical benefits directly to Prophase Diagnostics.
I agree to the declarations and term in the patient aknowledgment and irreversable assignment of benefits, I also authorize release of my results to my doctor utilizing all methods of transmission according to HIPAA regulations. Deidentified patient data may be used for R&D purposes.