I accept responsibility for all tests ordered from my office/clinic that are sent to Southwest Regional PCR/MicroGenDX Laboratory. I will still provide a requisition with each sample, which should be deemed as my written request to perform each specified test. I will inform Southwest Regional PCR/MicroGenDX Laboratory, at 1-855-208-0019, if I would like to end this electronic authorization agreement.
By my signature below, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge. I confirm that I have the authority to submit such an agreement. I also understand that any false statements or deliberate omissions on this form may subject me to legal actions for fraudulent misrepresentation.
To ensure privacy of patient information and correct delivery of patient reports to the proper individuals, please provide all of the following information regarding the requesting medical office. This is to ensure that the information we have on file is correct and to verify account details for registered accounts. This request may be extended to cover additional locations or emails in the future. For additional assistance, contact [email protected].