OIM TOX UTI Requisition MiraX

STOP

Please send this patient to their appropriate lab service provider or they will have to pay the CASH bill themselves to MIRA Genetix. Their HMO refuses to pay for services from your office.

STOP

Do not proceed with the UTI test. The test will not be covered and the patient will have to pay out of pocket for it.

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By clicking "Submit", you are requesting that the laboratory perform the complete toxicology panel as requested in your On Boarding packet, and that has authorized and requested these tests be performed for this patient. 

Please make sure the label on the bottle has the name and DOB filled out. This requisition will NOT BE COMPLETE until you have included the printed DEMOGRAPHICS form and included it in the mailer package to be sent to the laboratory.

By clicking below I am acknowledging that all the information included here is true and accurate to the best of my knowledge. 

Patient Authorization

I understand that MIRA Genetix is not a specimen banking facility and my samples will NOT be available after 60 days for future studies. De-identified samples may be stored in a repository and used internally for validation, educational and/or research purposes OR presented in scientific presentation for papers. In addition, de-identified information may be submitted in a HIPAA compliant manner to research databases. 

RELEASE AND CONSENT

As a courtesy MIRA Genetix makes every reasonable effort to obtain reimbursement for ordered tests. I authorize MIRA Genetix to release to Medicare, its carriers and any insurance carrier or Health plan providing benefits to me, any information that may be needed for claim purposes. I am making an assignment of Medicare, Medicaid, and/or insurance benefits to MIRA Genetix. I understand if my insurance company pays me directly for services rendered by MIRA Genetix I am responsible for forwarding such and all payments directly to MIRA Genetix. I also understand and agree that I am responsible for any copayment and/or deductible as required by my plan. I have read and understand the patient acknowledgment and consent. I permit a copy of this authorization to be used in lieu of original.

Patient Signs Here

Patient Signs Here

Optional Patient Question (Not Required)

Patient Initial Here