Request a Kit

By submitting this request, I confirm that the information provided above is accurate and that this bulk shipment request is being made on behalf of the practice or facility identified above. I understand this form is a request for RSM Diagnostics Lab to ship a bulk quantity of test collection kits, each including a blank Test Requisition Form (TRF), to be kept on hand at the practice or facility and distributed to patients in person, and that this form does not constitute a completed laboratory order for any individual patient.

I understand that RSM Diagnostics Lab will not process, accession, or perform any test until the completed and signed TRF included with a kit is returned with the specimen for the patient it was used for. I understand that the returned TRF, not this form, is the operative document establishing medical necessity, patient consent, and the ordering provider's certification and authorization to order the selected test(s) for that patient.

By submitting this request, I confirm that the information provided is accurate and that the ordering provider identified above is expected to order the selected test(s) for this patient. I understand this form is a request to ship a test collection kit, including a blank Test Requisition Form (TRF), to the identified patient, and that this form does not constitute a completed laboratory order.

I understand that RSM Diagnostics Lab will not process, accession, or perform any test until the completed and signed TRF included in the shipped kit is returned with the specimen. I understand that the returned TRF, not this form, is the operative document establishing medical necessity, patient consent, and the ordering provider's certification and authorization to order the selected test(s), and that any information provided here is subject to confirmation by the completed TRF.

This form is intended solely for practice, facility, and provider account setup, portal access, and test kit coordination for RSM Diagnostics Lab. It is not intended for submitting patient-specific clinical orders, test results, or other protected health information. Please do not enter any patient names, dates of birth, medical record numbers, diagnosis details, or other identifiable patient information in this form unless RSM has expressly requested such information through an approved process.

New York and California. RSM Diagnostics Lab does not offer services in either state. RSM will not accept, perform, process, ship, deliver, bill, or receive testing associated in any manner with New York or California, including any patient with a New York or California address, any specimen collected in, shipped from, shipped to, routed through, or otherwise connected to either state, or any account, practice, provider, or facility located in or operating from either state.

By submitting this form, you confirm that:

• You are authorized to provide the information on behalf of the practice or facility.
• All information you provide is accurate and complete to the best of your knowledge.
• You understand that incomplete, inaccurate, or unclear information may delay account setup, portal configuration, billing arrangements, or related processing, and may require follow-up.

Submission of this form does not:

• Create a provider-patient relationship with RSM Diagnostics Lab.
• Constitute a test order, medical diagnosis, or treatment recommendation.
• Guarantee account approval, specific billing arrangements, insurance coverage, or reimbursement for any tests.
• Alter RSM's obligations or rights under applicable federal and state laws, including but not limited to HIPAA, CLIA, Medicare, and commercial payer requirements.

RSM Diagnostics Lab maintains separate policies, procedures, and notices regarding privacy, data security, test ordering, billing, and regulatory compliance. Any use or disclosure of health information, if and when collected in appropriate clinical contexts, will be handled in accordance with applicable law and RSM's internal policies. This form and notice are intended to support accurate administrative intake and do not replace any required Notice of Privacy Practices, ordering documentation, or laboratory compliance obligations.

By using this form, you agree that RSM's separate contractual terms, privacy notices, and regulatory obligations govern all laboratory services and data handling, and that this form does not modify those terms.

This form is a request to ship a bulk quantity of RSM Diagnostics Lab test collection kits, each including a blank Test Requisition Form (TRF), to the identified practice or facility for in-office use. This form is not a laboratory order, does not identify any individual patient, and does not initiate specimen testing for any patient. RSM Diagnostics Lab will not accession, process, or perform any test until the completed and signed TRF included with a kit is returned with a specimen for a specific patient. The returned, signed TRF for that patient, not this form, is the operative document for purposes of medical necessity, patient consent, and ordering provider certification and authorization.

New York and California. RSM Diagnostics Lab does not offer services in either state. RSM will not accept, perform, process, ship, deliver, bill, or receive testing associated in any manner with New York or California, including any specimen collected in, shipped from, shipped to, routed through, or otherwise connected to either state, or any account, practice, provider, or facility located in or operating from either state.

This form does not request or contain patient-identifying information or protected health information (PHI). It is used solely to coordinate shipment of blank collection kit supply to your practice or facility. Any PHI associated with a specific patient's testing is collected separately, on the TRF returned with that patient's specimen, and is handled under RSM's separate HIPAA privacy and security policies.

By submitting this form, you confirm that:

• You are an authorized representative of an existing RSM Diagnostics Lab account and are permitted to submit this bulk kit request on behalf of the identified practice or facility.
• All information provided above is accurate and complete to the best of your knowledge.
• Your practice or facility will store the requested kits appropriately, monitor kit expiration dates, and follow standard TRF and ordering procedures for any patient to whom a kit is later distributed.

Submission of this form is a request for kit supply only. It does not itself identify or authorize testing for any patient, and does not guarantee kit availability, shipment timing, or delivery quantity.

RSM Diagnostics Lab maintains separate CLIA certification, laboratory quality procedures, HIPAA privacy and security policies, and billing and compliance procedures governing test performance, PHI handling, and claims submission for any test later ordered using a kit distributed through this request. This form and this notice support administrative intake for bulk kit supply only and do not modify, limit, or substitute for those separate policies, RSM's Notice of Privacy Practices, or any provider or facility services agreement.

RSM Diagnostics Lab reserves the right to decline, delay, or request clarification of any request submitted through this form where information is incomplete, inconsistent, unauthorized, or insufficient to support fulfillment of this request.

This form is a request to ship an RSM Diagnostics Lab test collection kit, including a blank Test Requisition Form (TRF), to the identified patient. This form is not a laboratory order, is not a substitute for the patient's medical record or the ordering provider's clinical documentation, and does not initiate specimen testing. RSM Diagnostics Lab will not accession, process, or perform any test until the completed and signed TRF included in the shipped kit is returned with the specimen. The returned, signed TRF is the operative document for purposes of medical necessity, patient consent, and ordering provider certification and authorization.

New York and California. RSM Diagnostics Lab does not offer services in either state. RSM will not accept, perform, process, ship, deliver, bill, or receive testing associated in any manner with New York or California, including any patient with a New York or California address, any specimen collected in, shipped from, shipped to, routed through, or otherwise connected to either state, or any account, practice, provider, or facility located in or operating from either state.

This form contains protected health information (PHI), including patient identifiers, contact information, and diagnostic information. This form is hosted within RSM's HIPAA-compliant Google Workspace environment, and RSM has executed a Business Associate Agreement with Google governing the processing of PHI within that environment. Access to this form and its responses is restricted to authorized RSM and practice personnel with a legitimate need to access the information, consistent with the HIPAA minimum necessary standard.

By submitting this form, you confirm that:

• You are an authorized representative of an existing RSM Diagnostics Lab account and are permitted to submit this request on behalf of the identified practice or facility and ordering provider.
• All information provided is accurate, complete, and consistent with the patient's medical record to the best of your knowledge.
• The ordering provider identified in this form is the individual RSM has on file as authorized to order the selected test(s) for this practice or facility, and that provider's National Provider Identifier (NPI) on file with RSM will be associated with this order.
• Required patient consent for specimen collection, testing, and release of results has been obtained by the ordering provider or practice before this request is submitted.

Submission of this form does not itself constitute a completed test requisition, does not replace any specimen collection or laboratory requisition documentation required at the time of specimen submission, and does not guarantee test performance, insurance coverage, or reimbursement. Coverage and billing determinations remain subject to the patient's insurance plan, medical necessity requirements, and applicable federal and state law, including Medicare and other payer-specific rules.

RSM Diagnostics Lab maintains separate CLIA certification, laboratory quality procedures, HIPAA privacy and security policies, and billing and compliance procedures governing test performance, PHI handling, and claims submission. This form and this notice support administrative and clinical intake for this request and do not modify, limit, or substitute for those separate policies, RSM's Notice of Privacy Practices, or any provider or facility services agreement.

RSM Diagnostics Lab reserves the right to decline, delay, or request clarification of any request submitted through this form where information is incomplete, inconsistent, unauthorized, or insufficient to support test performance or billing under applicable law.