By signing below, I authorize the following:
By providing my insurance information, I authorize Fibronostics to release information received, including without limitation, medical information, which includes laboratory test results, to my health plan/insurance carrier and its authorized representatives as necessary for reimbursement. I further authorize my health plan/insurance carrier to directly pay Fibronostics for the services rendered. I understand that I may receive a statement from Fibronostics for portions of this test not covered by my insurance or covered amounts applied to my unmet deductible. By selecting Self-Pay, I will not provide my insurance information, and I agree to provide Fibronostics payment. I understand that I will be contacted by an authorized representative from Fibronostics within 24hrs to collect the payment.

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I am a licensed medical professional. I acknowledge that the test requested herein is medically necessary and the patient is eligible for the test. I attest that the documentation of medical necessity for tests ordered is documented in the patient’s medical record, which will be made available upon request of performing laboratory and/or third-party payer. Note: Tests not ordered by the physician who is treating the beneficiary are not reimbursable. Order codes are updated but CPT Codes are not impacted.

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Fibronostics
3452 Lake Lynda Dr Building 100
Orlando, FL 32817

888-552-1603
www.fibronostics.com