Release of Records to Patient
Please fill out form completely with your information. Please fax back to 1-425-251-0637 or send via email to firstname.lastname@example.org.
Results Disclosure to Provider
Please fill out form completely with your alternate provider’s information. Please fax back to 1-425-251-0637 or send via email to email@example.com.
Patient Refund Request Form
If you need to fill out the Advance Beneficiary Notice of Noncoverage Form, you may download it here:
Female Hormone Panel Three Month Temperature Chart
If you meet any of the criteria below, your healthcare provider may instruct you to complete this temperature chart to determine the date to begin collecting for your Cycling Female Hormone panel.
- You have infrequent periods or no periods at all.
- You are experiencing any menopausal symptoms (hot flashes, migraines, night sweats, emotional fragility, etc.) and your periods are spaced four months apart or longer.
- You have had a hysterectomy (ovaries intact) and you are 55 years of age or younger.
If you are shipping your test kit to DiagnosTechs from outside the US, fill out and include this form. You do not need this form if you choose to purchase a UPS shipping label on DiagnosTechs’ website.
Carbohydrate Stimulation Test
If you need instructions and food choices for the Carbohydrate Stimulation Test, you may download this form.