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1. Demographics

Last Name:^*

First Name:^*

D.O.B.:^*

Gender:^*

Patient Street Address:^*

City:^*

State:

Zip:^*

Patient Phone Number:^*

Email Addres:^*

Home

Cell

Patient can receive text messages

Patient can receive emails

Weight:^*

lbs.

Height:^*

ft.

inches^*

BMI:

Insurance Co:

Insurance ID#:

Group #:

Insurance Address:

City:

State:

Zip:

2.Test Information

LIVERFASt 0166U

3. Insurance

Medicare

Commercial

Self-Pay

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.

Patient Signature:^*

Please type the name as signature

Signature Preview:
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Date:

4. Clinician Information

Clinician Name:

NPI Number:

Fax Number:

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.

Clinician Signature:^*

Date:

5. Additional Comments

FIBRONOSTICS US, INC.
274 E. Eau Gallie Blvd., #346
Indian Harbour Beach, FL 32937

888-552-1603
www.fibronostics.com

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