New Patient Forms

Patient Packet

This packet combines your Phlebotomy Consent Form, HIPAA Privacy Acknowledgment, Service Agreement, and Cancellation Policy into one document. Please read each section carefully and sign at the bottom.

Section 1 of 6

Patient Information

Patient Full Legal Name*

Date of Birth*

Age*

Medical Record / ID #

Phone*

Address *

City*

State*

ZIP Code

Section 2 of 6

Facility / Procedure Information

Facility / Clinic

Ordering Provider*

Time

Type of Collection *

Reason for Collection *

Section 3 of 6

Service Agreement

1. Services Provided

Blessed Hands Mobile Phlebotomy Services, LLC ("BHMPS") provides mobile phlebotomy and specimen collection services at the client's requested location within our service area.

2. Qualifications

All specimen collection is performed by a certified, trained phlebotomist. BHMPS maintains all required certifications and complies with applicable state and federal regulations.

3. Patient Responsibilities

Provide a valid government-issued photo ID at the time of service.
Provide a valid laboratory order from an authorized healthcare provider.
Disclose any known medical conditions, allergies, or medications.
Follow any pre-collection instructions (e.g., fasting requirements).
Ensure a safe and accessible environment at the service location.

4. Payment and Fees

Payment is due at the time of service unless prior arrangements have been made. If billing to insurance, the patient is responsible for any amounts not covered by their plan.

5. Cancellation

We require at least 24 hours' advance notice for cancellations or rescheduling. Late cancellations may incur a $25.00 fee; no-shows may incur a $35.00 fee.

6. Limitation of Liability

BHMPS is not responsible for laboratory results, diagnoses, or treatment decisions. Our responsibility is limited to proper collection, handling, and transport of specimens.

7. Right to Refuse Service

BHMPS reserves the right to refuse or discontinue service if the location is unsafe, the patient is uncooperative, or the service falls outside our scope of practice.

8. Governing Law

This agreement is governed by the laws of the State of Texas. Disputes shall be resolved in the appropriate courts of Midland County, Texas.

Service Type *

Payment Method *

Service Location / Address

I will be billing insurance

Section 4 of 6

HIPAA Privacy Notice & Acknowledgment

Our Commitment to Your Privacy

Blessed Hands Mobile Phlebotomy Services, LLC is committed to protecting the privacy of your health information (PHI) in accordance with HIPAA and applicable state laws.

How We May Use Your Health Information

Treatment: To provide, coordinate, or manage your healthcare and related services.
Payment: To obtain payment for services rendered, including billing your insurance.
Healthcare Operations: For internal operations such as quality assessment and compliance.
As Required by Law: When required by federal, state, or local law.
Business Associates: With third-party business associates who agree to protect your information.

Your Rights

Right to inspect and copy your PHI.
Right to request an amendment to your PHI.
Right to request restrictions on certain uses and disclosures.
Right to request confidential communications.
Right to file a complaint with HHS Office for Civil Rights.

A personal representative is completing this form on behalf of the patientI would like to request a restriction on certain uses or disclosures of my health informationI would like to request confidential communications at an alternate address or phone number

Section 5 of 6

Policies

Informed Consent Statement

I understand that phlebotomy is the collection of a blood sample by needle stick or finger stick for laboratory testing. Common risks may include temporary pain, bruising, bleeding, lightheadedness, hematoma, and, rarely, infection or nerve irritation. I understand I may refuse or stop the procedure at any time. Test results will be handled in accordance with applicable privacy and confidentiality requirements.

Mobile Draw Policy

By requesting a mobile draw, I agree to the following:

I or a responsible adult will be present at the designated location at the scheduled appointment time. A $25 trip fee may apply for missed or cancelled appointments with less than 24 hours notice.
I will provide a safe, clean, and adequately lit environment for the phlebotomist.
BHMPS reserves the right to reschedule or decline service if the environment is deemed unsafe.
All specimens will be transported to the designated laboratory in accordance with proper chain-of-custody protocols.
Results will be released to the ordering provider. BHMPS does not interpret or release laboratory results to patients.

Physician Order Policy

A valid physician order is required for all laboratory specimen collections. I confirm that:

A written or electronic laboratory order from a licensed, authorized healthcare provider will be presented at or prior to the time of collection.
Orders must include the patient's full name, date of birth, tests requested, and the ordering provider's name and credentials.
BHMPS reserves the right to decline collection if a valid order cannot be verified.

Cancellation Policy

I understand and agree to the following cancellation terms:

A minimum of 24 hours' advance notice is required for all cancellations or rescheduling requests.
Late cancellations (less than 24 hours) may be subject to a $25.00 cancellation fee.
No-shows are subject to a $35.00 no-show fee, which must be paid before a new appointment can be scheduled.
After two no-shows, BHMPS reserves the right to require prepayment for future appointments.

Consumer-Friendly Testing Consent

If I am requesting consumer-friendly (direct-to-consumer) laboratory testing, I understand and agree to the following:

No doctor's order is required for consumer-friendly testing. Tests are self-ordered and results will be released directly to me.
Blessed Hands Mobile Phlebotomy Services, LLC (BHMPS) provides specimen collection services only and does not diagnose, treat, or provide medical advice. BHMPS is not responsible for test results.
Testing is performed by a certified laboratory.
I agree to assume full financial responsibility for all laboratory tests and services requested. Payment is due prior to specimen collection and services will not be performed until payment has been received. No insurance billing is provided unless otherwise specified.
A mobile fee may apply in addition to laboratory fees. All fees will be disclosed prior to scheduling.
I agree to seek medical advice, care, and treatment from my healthcare provider regarding any questions, concerns, test results, symptoms, or medical conditions. If I become ill or experience symptoms, I will contact my healthcare provider or seek appropriate medical attention.
Prices are subject to change without notice. Prices include travel fee.

Section 6 of 6

Signature & Date

By signing below, I confirm that I have read and understood this entire patient packet, including the Phlebotomy Consent Form, HIPAA Privacy Notice & Acknowledgment, Service Agreement, Cancellation Policy, and Consumer-Friendly Testing Consent (if applicable). I voluntarily consent to the services described and agree to all terms and policies outlined above.

Patient / Representative Signature*

Date*

For Staff Use Only

Staff Member Name

Credentials

Staff Signature

Date

Witness Name / Signature

Witness Date

Note: This packet is for informational and administrative use. Facilities should review and adapt these forms for state-specific consent requirements, payer rules, and any test-specific disclosures.