Carrier Screening Test

I have read the Informed Consent document and I give permission to MVL to perform carrier screening testing as described. I also give permission for my specimen and clinical information to be used inde-identified studies at MVL and for publication, if appropriate. My name or other personal identifying information will not be used in or linked to the results of any studies and publications.

Order Provider

I attest that the patient has received and read the MVL Informed Consent document, or has had it read to him or her, and that I have fully informed the patient about the purpose, capabilities, and limitations of the ordered test. The patient has voluntarily given his or her full consent for the ordered test and a signed copy of this consent is available on file. Any MVL Informed Consent that the patient agrees to at a later date will supersede and replace this Informed Consent.

STATEMENT OF MEDICAL NECESSITY
By signing below, I, the ordering Medical Provider, confirm that testing is medically necessary and that test results may impact medical management for the patient.

$20 fee has been added for MVL Prescription Service (Selected under "Applicant > Referral Information")

Insurance Billing

Attach front and back of all insurance cards, ABN, medical criteria form.

By signing below, the patient or insured authorizes MVL to release medical information concerning the test to the assigned insurance company.

If I am covered by insurance, I authorize MVL and their contracted billing company to give my insurance carrier the information on this form and provided by my healthcare provider that is necessary for reimbursement. I understand that I am responsible for deductible
and coinsurance amounts as indicated by my insurance carrier. I agree to assist in resolving insurance claim issue ans if I do not assist, I may be responsible for the cost of the test. I understand that I am responsible for sending MVL any and all of the money that I receive directly from my insurance carrier in payment for this test.

If the test is not authorized by or is not covered by my insurance, than I will be contacted with the option to either cancel the ordered test or elect to pay out-of pocket according to the proposed payment plan provided to me when I am contacted. If I elect to pay out-of-pocket, I will be responsible for all payment obligations arising from the ordered testing and guarantee payment for these services. I understand that if payments or arrangements are not made after 3 statements my information may be sent to collections.

MVL is committed to support you with your share of costs. If required, you will be contacted by our team to setup a payment plan for your portion of the costs using the following forms of payment: Check, Visa, Master Card. You may also contact our office at 503-227-3179.

Self Pay

By filling out the information below, the patient or payor authorizes Molecular Vision Lab to contact them directly, and use the provided billing instructions to bill the indicated method.

No charges will be posted until we receive your sample. Your card information will be handled using Stripe's secure online payment station. No card information is kept with the lab.

Institutional Billing