Consent to Test: I authorize the lab to test and release results to the ordering provider. Health Coverage: I authorize payments be made to the lab for the
laboratory services ordered by my provider. I authorize my provider and provider’s medical staff, as well as my health plan providing medical benefits to
release to the lab any information needed to determine coverage for laboratory services. I understand I am responsible for payment of any deductible
and co-insurance charges. If my health plan providing medical benefits makes payment for laboratory service to me, I understand that I am responsible for making the payment to the laboratory for services rendered. Self-Pay: I accept full financial responsibility for payment associated with the laboratory
tests ordered by my provider.