Laboratory Work Policy

Please correct the errors described below.

Attention Patient / Responsible Party:

You are responsible for all the laboratory charges for all specimens taken/sent to any private or outside laboratory, including (but not limited to) Sonora Quest, LabCorp, Lab Express, and Prometheus. These private laboratories are not part of PATTERSON PEDIATRIC GASTROENTEROLOGY. As such, they will bill you and /or your insurance carrier separately from any of our charges.

PATTERSON PEDIATRIC GASTROENTEROLOGY will make a good faith effort to send you to a contracted facility. However, it is ultimately your responsibility to ensure that all services for medical care are rendered by a provider contracted with your insurance carrier. Therefore, if your insurance carrier denies your laboratory services for any reason, including that the laboratory is not contracted, PATTERSON PEDIATRIC GASTROENTEROLOGY WILL NOT BE HELD LIABLE FOR YOUR LABORATORY CHARGES/ FEES.

We reserve the right to deny services to any person whom fails to comply with the above information.

I HAVE READ AND AGREE TO THE ABOVE INFORMATION. I UNDERSTAND THAT I AM RESPONSIBLE FOR ENSURING THAT ALL SERVICES ARE RENDERED BY A CONTRACTED PROVIDE. FURTHER, I AGREE AND UNDERSTAND THAT I AM PERSONALLY AND FULLY RESPONSIBLE FOR ALL LABORATORY CHARGES IN THE EVENT MY INSURANCE CARRIER DENIES THE LABORATORY CLAIM FOR ANY REASON. FINALLY, I AGREE THAT PATTEROSN PEDIATRIC GASTROENTEROLOGY WILL NOT BE HELD RESPONSIBLE FOR MY LABORATORY CHARGES.

ESPANOL

Paciente / Entidad Responsable:

Usted es responsable de todos los cargos de laboratorio para todas las muestras tomadas/ enviado a cualquier laboratorio privado o en el exterior (pero no limitadosa) Sonora Quest, Labcorp, Lab Express, y Prometheus. Estos laboratorios privados no son parte de Patterson Gastroenterologia Pediatrica. Como tal, se le facturaran a usted y o su compania de seguros por separado de cualquiera de nuestros cargos.

Patterson Gastroenterologia Pediatrica hara un esfuerzo de buena fe para enviarle a un centro contratado. Sin embargo, es en ultima instancia su responsabilidad asegurarse de que todos los servicios de atencion medica son prestados por un proveedor contratado con su compania de seguros. Por lo tanto, si su compania de seguros niegasus servicios de laboratorio por cualquier razon, incluyendo la camiseta que el laboratorio no se contrae, Patterosn Gastroenterologia Pediatrica NO SE HACE RESPONSABLE DE SUS CARGOS DE LABORATORIO/CUOTAS.

Reservamos el derecho de negar servicios a cualquier persona que no cumpla con la informacion anterior.

He leido y acepto la informacion anterior. Entiendo que soy responsable de asegurar que todos los servicios son prestados por un contratado proveer. Ademas, acepto y entiendo que soy personalmente y totalmente responsable de todos los cargos de laboratorio en caso mi seguro niega la reclamcion de laboratorio por cualquier motivo. Finalmente, estoy de qcuerdo que Patterson Gastroenterologia Pediatrica NO SE HACE RESPONSABLE DE MIS GASTOS DE LABORATORIO.

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