This form is used to authorize additional testing be performed on a specimen already at MLabs for which we do not already have a written order. According to CLIA regulation # 493.1105, MLabs must receive written authorization from a client within 30 days of a verbal request.
This Clinical History Form (C), which is used for a prior authorization. For full details on how to fill out the Clinical History Form (C), please download the Prior Authorization Packet.
Complete the first three sections of this form and submit with specimens sent for blood lead or heavy metal screen analysis.
MLabs will require that all requests for molecular tests are accompanied by this form AND a recent pathology report, relevant clinic encounter notes, or medical genetics consultation.
This form can be used to provide or revise ICD-9 or ICD-10 code(s) submitted for insurance carrier billing.
The ordering clinician or an individual to whom the clinician has delegated authority is required by Michigan law to obtain the written informed consent of the test subject for pre-symptomatic or predictive genetic testing. By ordering such genetic testing from MLabs the clinician acknowledges that informed consent has been obtained from the patient as required by applicable state or federal laws and the ordering clinician has authorization from the patient permitting MLabs to report the test results to the ordering clinician.