This is to certify that I consent to and authorize Gunnison Valley Health/Gunnison Valley Hospital (collectively, “Hospital”) to collect my blood and/or urine for analysis of the marked Direct Access Testing. Direct Access Testing (“DAT”) is patient-initiated testing that does not require a physician's order. I authorize the Hospital to release my results to me through the method indicated on this form. In performing the patient-initiated testing, I understand that Hospital is not acting as my doctor, that this does not replace treatment by a physician and that I assume complete and full responsibility to take appropriate action regarding test results, up to and including consulting with a physician. In this regard, I do not and will not hold the Hospital responsible for my test results and absolve them and their affiliates of any liability. I agree that I will seek medical advice, care, and treatment from my usual source of health care if I have questions or concerns, have any symptoms of illness, or become ill. I understand that the venipuncture process involves a small medical risk and may result in bruising around the area from which the blood is taken. In the event of an accidental needle puncture to Hospital’s staff member involved in the blood collection process, I consent to any routine blood test deemed necessary for the safety of the phlebotomist. As with laboratory testing of any nature, the potential for falsely elevated, lowered, positive or negative laboratory values is present.
I agree to take full fiscal responsibility for the tests requested, and I understand that payment is required prior to specimen collection. I understand that the DAT I am requesting on the attached form will not be billed to a third party by Hospital and that my results will not be sent to a physician or health care provider, though the results will be available for review in my medical record and patient portal. Certain Providers may be able to access results electronically via QHN.
I understand the cost of DAT may increase in the future without prior notice. I understand that medical insurance does not usually cover the cost of DAT and usually will not reimburse these charges or apply them towards a deductible when they are not ordered by a physician. I accept full responsibility for inquiring with my insurer in this regard.