Dear Patient,
During your office visit today or any visit in the future, you may have some lab work or blood work that is processed in an outside laboratory. The charges for these test are set by the laboratory, not by our office.THIS FEE IS NOT PART OF YOUR OFFICE VISIT.
Some tests are done routinely as part of your annual exam, ob care, or if the doctor suspects that you may have an infection. YOU WILL RECEIVE A SEPARATE BILL FROM AN INDEPENDENT LAB FOR THE PROCESSING OF THIS LAB WORK OR BLOOD WORK. Currently the lab of choice for this office is LabCorp. If your insurance requires that you use another lab, please state the lab on the line below.
My insurance company requires me to use ___________________________________
for the processing of all lab or blood work.
I am also aware that Georgia Law requires that I give informed consent for any blood draw from my arm. The risks from this procedure includes bruising at the needle stick site or in the rare instance, infection.
I have read the above information and I agree to the terms within.
Signature:____________________________________ Date: __________________
REFUSAL
I have read the above information and I refuse any lab work or blood work that may need to be processed by an outside lab. I understand that without these test this office will not be responsible for missed diagnosis or untreated sexually transmitted diseases.
Signature: ___________________________________ Date: __________________
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