Report Delivery Options:
Additional Provider Information if applicable:
1. I have received and reviewed the complete list of tests offered by Qualitox Laboratories and/or its affiliates.
2. Decisions on ordering laboratory testing are based solely on the medical necessity for specific medical conditions. The provider understands that when ordering tests for which Medicare reimbursement will be sought, the treating provider should only order those tests which the physician believes are medically necessary for each patient. The provider has been informed that the Office of Inspector General (OIG) takes the position that a provider who orders medically unnecessary tests may be subject to civil penalties.
3. I understand that individual tests or a less inclusive profile should be ordered when not all of the tests in the custom profile are medically necessary. I understand that using a customized profile may result in the ordering of tests in which Medicare or other federally funded health care programs may deny payment.
4. It is agreed that all supporting medical necessity documentation should be available, legible, and maintained in the patient's medical record.
5. Patients have been informed that consent to the collection and testing of specimen provided and authorize QualiTox Laboratories and/or its affiliates to release the result of testing to the ordering facility.