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As part of my antibiotic stewardship policy, I find it medically necessary to rapidly determine and differentiate a viral and/or bacterial infection in order to treat with or without appropriate antibiotics. Having the most accurate and timely data available to me directly guides my treatment and patient management. Empiric treatment and management leads to inappropriate and unnecessary antibiotic use (50% according to the CDC) and delayed diagnosis which can lead to severe consequences. Standard antibody/antigen detection is only available to detect few pathogens and comes with a high false negative rate, relatively lower sensitivity (60-70%) and specificity (80-90%). In addition, standard antibody/antigen detection requires the infection to be present for days allowing the body to make ample antibodies in order to detect. Qualitative Nucleic Acid Amplification Testing (NAAT) is far superior with sensitivities and specificities > 98% and available to detect many pathogens. In addition, NAAT has built in controls to determine if an adequate patient sample was collected and processed, therefore greatly reducing false negative results. NAAT also includes controls to easily determine a contaminated sample, therefore reducing false positive results.
For non-touch screen devices, the patient needs to type their full name below, and provide a secondary identifier.
By selecting the Add Signature button, I attest that I approve of this digital signature
I certify that I have voluntarily provided a fresh and unadulterated specimen for analytical testing. The information provided on this form and on the label affixed to the specimen is accurate. I hereby authorize Promus DIAGNOSTICS Solutions or its assignee to bill any and all insurance/health coverage on my behalf for laboratory services rendered by a performing CLIA Laboratory. I irrevocably assign to and direct that payment be made to Promus DIAGNOSTICS Solutions company or assignee as designated by company. I also authorize Promus DIAGNOSTICS Solutions to release any information required for billing and reimbursement. I further authorize a performing CLIA Laboratory to release the results of this testing to the treating authorized healthcare provider or facility. I acknowledge that Promus DIAGNOSTICS Solutions may be out-of-network facility/provider with my insurance provider. I am also aware that in some circumstances my insurance provider may send payment directly to me. I agree to endorse the insurance check and forward it to Promus DIAGNOSTICS Solutions within 15 days of receipt as payment towards the lab services provided by a performing CLIA Laboratory. I acknowledge that I am responsible for any amounts not covered by my insurer including any deductibles and co-payments/co-insurance. I understand that a performing CLIA Laboratory may use my specimen and any testing performed on that specimen for research and development so long as the information has been de-identified pursuant to law.
Physician Signature / Date
Patient Signature / Date