I agree to the declarations and terms in the patient acknowledgment and irrevocable assignment of benefits.I understand that if do not have insurance, I will be billed directly by Prophase Diagnostics. I also authorize release of my results to my doctor utilizing all methods of transmission according to HIPAA regulations. De- identified patient data may be used for R&D purposes.
I acknowledge that documentation to support medical necessity for all tests ordered is recorded in the patient's chart. If not signed, Authorized Healthcare Provider affirms that test orders are placed in patient file with provider signature and will be available upon request. The Office of the Inspector General requires documentation in patient medical chart including date of service, tests ordered and documentation to support medical necessity.