Request a Kit

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.

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.