Provider Disclosure Form Regarding Laboratory Services
During the course of your provider/patient relationship with all providers at Meridian Advanced Psychiatry (MAP), these providers will order certain laboratory tests for purposes related to your medical care and treatment. In connection with any laboratory services performed by the Laboratories located at 1672 Woodsage, Meridian, ID 83642, you are hereby advised that Kyle Ronnau has a financial interest in the Laboratories.
This information is being provided to help you make an informed decision about your health care.
You have the right to choose your laboratory. You have the option of obtaining the laboratory services ordered at a different laboratory other than the Laboratories at the address above. You will not be treated differently by your providers or any staff at MAP if you choose to use a different laboratory.
Your signature below evidences your receipt of this Provider Disclosure Form and that you have been informed of your ability to have your laboratory services performed by a different laboratory.
Further, you acknowledge by signing below that you have read and signed this Provider Disclosure Form prior to having your laboratory services performed at the Laboratories.
By signing below, you acknowledge that your laboratory services will be performed at MAP, but that you always have the ability to choose a different laboratory if and when you choose upon providing written notice to MAP of such choice to use a different laboratory and the name and contact information of that laboratory.
To assist you in making an informed decision on where to obtain laboratory services, please be aware that the following laboratories may serve as alternative providers:
Sterling Reference Laboratory, 2205 North Monroe Street, Spokane, WA (509) 327-3542
Pathology Associates Medical Laboratories, 110 Cliff Drive, Spokane, WA (509) 755-8991
Millennium Laboratories, 11501 Rancho Bernardo Rd. San Diego, CA (877) 451-3534
Quest Diagnostics, 1737 Airport Way South, Ste 200, Seattle, WA (206)623-8100
AIT Laboratories, 2265 Executive Dr. Indianapolis, IN (800) 875-3894