OIM TOX UTI Requisition SilverStar

STOP

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

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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 Dr. Ricky Lockett 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 SilverStar Diagnostic 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. 

Patient Authorization

I understand that Pure Diagnostic 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 SilverStar Diagnostic makes every reasonable effort to obtain reimbursement for ordered tests. I authorize SilverStar Diagnostic 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 SilverStar Diagnostic. I understand if my insurance company pays me directly for services rendered by SilverStar Diagnostic I am responsible for forwarding such and all payments directly to SilverStar Diagnostic. 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