Consent/Insurance Release: I, the undersigned, understand and grant permssion to
to bill my insurance for laboratory services provided. I undrerstand
that
services provided may not be covered by my insurance. I further understand that I will not be
responsible for co-pays, deductibles, andany amount not covered by my insurance. By signing below, I
acknowledge that payment may be made on my behalf to One Love Laboratory. I hereby authorize the
ordering physocan and/or clinic to disclose any personal or medical information that may be needed
to process claims related to services rendered by One Love Laboratory and its affiliates. I
understand that my records may be protected under 42 CFR Part 2, under which i may
revoke my consentat any time execpt to the extent that action has been takenin reliance on it, and
that in anyevent this consent expires six(6) months after the date of program discharge.
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