Agent Signature

Agent Declaration

As an authorized agent responsible for delivering PacGenomics test kits to designated collection sites, I hereby confirm and attest that:
All tests are performed by the patients themselves at the collection sites.
There is no falsification, misrepresentation, or concealment in the testing process.
All patient information provided is true, accurate, and valid.
By acknowledging this declaration, the agent affirms their responsibility to uphold the integrity and accuracy of the testing process. Once I have completed HIPAA training and begin submitting test kits, it is understood that I have read and agreed to this declaration.

Physician Signature Authorization

This link is provided to securely record your signature for use on PacGenomics’ COVID-19 PCR, COVID-19 Rapid, and Respiratory Panel requisition and consent forms.
By signing, you hereby certify and authorize that:
The tests requested on these forms are medically necessary for the patients you refer, and the appropriate diagnosis codes have been indicated based on each patient’s medical record.
Documentation supporting medical necessity for all ordered tests has been, or will be, recorded in the patient’s medical chart and made available upon request.
PacGenomics may use your recorded signature on requisition forms and consent forms for patients you refer, and your name and professional information may appear on the corresponding laboratory reports.
Failure to provide a physician’s signature requires that all test orders be fully documented in the patient’s medical chart and available upon request.