Riskguard^® ordering provider attestation

As the ordering Healthcare Provider, I certify that:

1. I am a qualified health care provider who is legally authorized to order this test and this testing is medically necessary and appropriate for this patient and the results will be used to determine the patient’s treatment plan;
2. I have obtained the patient’s informed consent to perform this test;
3. I have received the patient’s consent for your laboratory to release test results and submit all necessary information to insurance for payment; and
4. I understand this testing will be based on the most updated requisition and test description available.