Neurotrauma Assessment Test Requisition Form
Ordering Provider Name (Print) and NPI:
PATIENT INFORMATION
PATIENT PAYMENT / BILLING INFORMATION
CLINICAL HISTORY & SYMPTOMS OF TBI
Date of Injury:
Please attach patient’s clinical history to this form.
TEST ORDER
Collection
PATIENT ACKNOWLEDGMENT AND INFORMED CONSENT
I request and authorize Healix Pathology, LLP to perform the designated test(s) on the biological specimen(s) provided by me. My signature below constitutes my acknowledgment that I have been informed of the benefits and limitations of this testing which have been explained to my satisfaction by a qualified health professional. I also understand that reference/testing lab reserves the right to provide de-identified information of a statistical nature to accrediting agencies and reserves the right to use such anonymous information. Donor Signature: I certify that I provided my specimen to the collector, that I have not adulterated it in any manner; each specimen used was sealed in my presence; and that the information provided on this form and on the label affixed to each specimen is correct. I authorize the release of the results to the ordering clinician, authorized client/representative, or prescribing/attending physician. I authorize the entity to release any information required for billing purposes. The lab is authorized to bill my insurance provider, or any payer, whether fully insured or selfinsured, and I will irrevocably assign any payment of benefits, claims, rights, and interests related to the services my healthcare provider performed against any payer. I further authorize the lab and my healthcare provider to release to my insurance provider any medical information necessary to process this claim. I acknowledge that Healix Pathology may be an out-ofnetwork facility/provider with my insurance provider. I am also aware that in some circumstances my insurance provider may send the payment directly to me. I agree to endorse the insurance check and forward it to Healix Pathology within 15 days of receipt as payment towards the lab services provider by Healix Pathology. I acknowledge that I am responsible for any amounts not covered by my insurer including any deductibles and co-payments/co-insurance.
I also give permission for my specimen and clinical information to be used in de-identified studies at Healix Pathology LLP and Healix Clinical Laboratory LLC and for publication, if appropriate. My name or other identifying information will not be used in or linked to the results of any studies and publications.
AUTHORIZED HEALTHCARE PROVIDER ACKNOWLEDGMENT
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.
