Alternative Payment Method
This company does not accept all insurance payers. You may choose to file you claim by submitting a copy of this receipt to your insurance carrier. This company accepts no responsibility on how your insurance will respond to your claim or whether the service is a covered benefit.
I (we) hereby authorize this company to initiate a change to my (our) credit card to pay for the services rendered. I(we) acknowledge that the origination of such transactions to my (our) account must comply with the provisions of US law.
I , request and permit these provider to analyze the sample indicated on the test requisition form in My sample, My child's sample. No testing apart from that which is selected will be performed. Additional testing requires my additional, express consent.
By signing below, I attest to the following: