Direct Access Laboratory Testing Consent

Patient Identification Label
Name
MRN
DOB
Date of Service

This is to certify that I consent to and authorize (facility) __________________________________________________________________________

to collect my blood and/or urine for analysis of the marked Direct Access Laboratory Testing. Direct Access Testing (DAT) is patient-initiated testing that does not require a physician’s order. I authorize UCHealth to release my results to me through the My Health Connection Patient Portal. I understand that the UCHealth Laboratory is not acting as my doctor, that this does not replace treatment by a physician and that I assume complete and full responsibility to take appropriate action with regard to test results, up to and including consulting with a physician. In this regard, I do not and will not hold the UCHealth responsible for my test results and absolve them and their affiliates of any liability. I agree that I will seek medical advice, care, and treatment from my usual source of health care if I have questions or concerns, have any symptoms of illness, or become ill. I understand that the venipuncture process involves a small medical risk and may result in bruising around the area from which the blood is taken. In the event of an accidental needle puncture to the UCHealth staff member involved in the blood collection process, I consent to any routine blood test deemed necessary for the safety of the phlebotomist. As with laboratory testing of any nature, the potential for falsely elevated, lowered, positive or negative laboratory values is present.

I agree to take full financial responsibility for the tests requested, and I understand that payment is required prior to specimen collection. I understand that the DAT I am requesting on the attached form will not be billed to a third party by UCHealth and that my results will not be sent to a physician or health care provider, though the results will be available for review in my medical record. Should my provider review my results and request additional tests on the specimens collected by DAT, these add-on tests will be billed as physician-ordered tests and my insurance company may be billed for the additional tests only. If add-on tests are requested by my provider, please bill as follows (choose one option):

Bill me.
_______Initial here if selected.

Bill my insurance (A copy of your insurance information is required.)
_______Initial here if selected.

I understand the cost of DAT may increase in the future without prior notice. I understand that medical insurance generally does not cover the cost of DAT and usually will not reimburse these charges or apply them towards a deductible when they are not ordered by a physician. I accept full responsibility for inquiring with my insurer in this regard. I understand that additional tests may be performed if requested by my physician and those tests will be billed as I have indicated above.

I will access my results via UCHealth’s My Health Connection patient portal.

DO NOT SIGN UNLESS YOU HAVE READ AND THOROUGHLY UNDERSTAND THIS FORM.

Name of Patient Date of Birth
Signature of Patient or legally authorized representative (if under age of 18) Phone number for emergent/critical lab results
Relationship to patient
Date Time

CERTIFICATION OF INTERPRETER SERVICES (if the patient’s preferred language for health care is not English). I have communicated the information on this form and any explanations to the patient using a Qualified Medical Interpreter in the patient’s preferred language, or by speaking to the patient as a Qualified Bilingual Provider.

Interpreter Name or number
Qualified Bilingual Provider Yes  No 