Cathy P. Milam, M.D.

Megan M. Bogart, M.D.

Brooke Robbins, APRN

Molly Prichard, APRN

George Anderson, PA

Please Print (Last Name) (First Name) (M.I.)

Due to multiple requirements and restrictions that different insurance companies have on

laboratory specimens we just want to emphasize that it is the patient’s responsibility to keep us

updated on their insurance company’s restrictions on where to send pathology specimens. If

we do not have the appropriate information we cannot follow your insurance company’s

requirements.

Examples of the restrictions are that some United Healthcare plans have informed us that we

need preapproval prior to sending the specimens to the laboratory. United Healthcare has told

us that this can cause at times a ten delay in getting results back.

Any lab fees that result from us not having this information are patient’s responsibility.

Signature of the Patient or Legal Guardian: _______________________ Date: ___________