Provider Certification

I hereby authorize AccessDx Laboratory to perform the requested testing, which is medically reasonable and necessary. I certify that I have explained the purpose of and need for this testing to the individual/family member authorized to make decisions for the individual and supplied information regarding and consented to undergo genetic testing, as set forth in AccessDx’s Informed Consent for Pharmacogenomics Testing (https://www.accessdxlab.com/-forms). If insurance billing is selected, the patient has been informed and authorizes AccessDx and its designees to release information concerning testing to their insurer. I agree to allow AccessDx to transfer the information from this requisition to a letter of medical necessity and/or other documentation using the medical professional’s name as the signature when necessary having provided advance notice to the medical professional and without receiving objection thereto. I acknowledge that the patient has agreed that if the patient’s insurer does not reimburse AccessDx in full for any reason then AccessDx may bill the patient for the services and the patient will remit payment to AccessDx. For amounts the patient receives from the insurer, the patient has agreed to remit payment to AccessDx for services rendered. I understand that some of the genes tested, such as APOE, F2, and F5, have inherited disease risk implications that should be reviewed in addition to drug-gene interactions. By completing this order, I certify that I am the ordering provider, I am authorized by an ordering provider to order this test, or I am authorized under applicable state law to order this test.