ABN: I request and authorize KPC Biotech Molecular Laboratory to perform the designated test(s) on the DNA sample provided by me.  My signature above constitutes my acknowledgement that I have been informed of the benefits and limitations of this testing which have been explained to my satisfaction by a qualified health professional.  I also understand that reference/testing lab reserves the right to provide de-identified information of a statistical nature to accrediting agencies and reserves the right to use such anonymous information.
Assignment of Benefits: I hereby authorize the entity to bill my insurance company and receive payment from them on my behalf.  I acknowledge, however, that I am responsible for payment of my account and any and all charges associated with it’s collection.  I hereby authorize the entity, or their designee, to appeal my health plan on my behalf to provide the actions and information necessary to overturn the denial or receive reimbursement for the underpaid claim.  This authorization shall remain valid until the charges for the orders on this form are paid in full.