Electronic Signature Authorization Form

The Electronic Signature Authorization Form (ESAF) must be signed by each ordering provider in your office in order for Diagnostic Solutions Laboratory to enter insurance claims for your patients. Once we have the signed signature authorization on file, you will not have to sign the Test Request Form each time you order testing for your patient. This form is used for any test order and Insurance/Medicare Claim.

The health care provider’s signature on the requisition proves to the patient’s Insurance that you intended to order the selected laboratory test(s). As a Medicare provider, Diagnostic Solutions Laboratory must obtain your signed order or documentation of intent to order diagnostic laboratory tests in order to comply with Medicare, other government payor, or any commercial insurance requirements.

The Electronic Signature Authorization Form will be kept on file. Orders added through the provider portal will be stamped with > signature on file < if drop-shipped directly to the patient.

Access and download the form below (PDF opens in a new window).

Electronic Signature Authorization Form