HepC Alliance Lab Test Consent Name:____________________________________________ Gender: M F Birth date:_______________ Address: __________________________________________ City: _____________ State: _________________ Phone: ________________________ Ordering Clinician:_________________________ NPI#:____________ Test Site ID :_____________ List Test Ordered Below: TEST CODE TEST NAME I have requested lab testing as order by my doctor or nurse. I understand that Hepatitis C is a reportable disease, and that lab testing involves a blood test and that this test, while confidential, will not be provided to individuals seeking anonymous testing. Your responses to the above are confidential, and HepC Alliance or authorized researchers may use the information you provide in research; however, no information that would make it possible to identify you will be included in any reports. In addition, I authorize the County Health Department, Testing Site, and the HepC Alliance to contact me regarding the results of my lab tests. ____________________________________ _____________________________________ Signature Date Lab Tech or Nurse Date Last 4 of SSN __________ Effective date: 1-1-2015 FAX THIS FORM TO: 573-442-6736 WITHIN 72 HOURS OF SUBMITING THE REQUSITION TO QUEST!
HepC Alliance Lab Test Consent Name:____________________________________________ Gender: M F Birth date:_______________ Address: __________________________________________ City: _____________ State: _________________ Phone: ________________________ Ordering Clinician:_________________________ NPI#:____________ Test Site ID :_____________ List Test Ordered Below: TEST CODE TEST NAME I have requested lab testing as order by my doctor or nurse. I understand that Hepatitis C is a reportable disease, and that lab testing involves a blood test and that this test, while confidential, will not be provided to individuals seeking anonymous testing. Your responses to the above are confidential, and HepC Alliance or authorized researchers may use the information you provide in research; however, no information that would make it possible to identify you will be included in any reports. In addition, I authorize the County Health Department, Testing Site, and the HepC Alliance to contact me regarding the results of my lab tests. ____________________________________ _____________________________________ Signature Date Lab Tech or Nurse Date Last 4 of SSN __________ Effective date: 1-1-2015 FAX THIS FORM TO: 573-442-6736 WITHIN 72 HOURS OF SUBMITING THE REQUSITION TO QUEST!