Patient Consent for Lab Ordering

Authorization

By filling this out, you consent to the Rupa Health team contacting you about labwork ordered by your provider. We will contact you via email to collect and invoice for labs, and act as your point of contact for any questions around completing the labs. The Rupa Health team may also communicate with your practitioner about lab-work ordered for you.
For any questions, contact support@rupahealth.com.
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I authorize the Rupa Health Team to order and handle lab work on behalf of my provider and communicate with me via email regarding my health information.*

Your Information

This information is used to auto-populate your lab requisition forms.

Note, we don't ship to NJ, NY, and RI at this time.

Insurance Information

Your doctor indicated to us that you will be using insurance to cover your testing. How Insurance Works

If you have Medicare, either as primary or secondary insurance, lab test pricing is different. Please reach out to us at support@rupahealth.com and we’ll update the billing for your order.

Medicare Information

Your doctor indicated to us that you will be using Medicare to cover your testing.

Lab test pricing is different for Medicare Advantage or Medicaid. If you have one of these, reach out to us atsupport@rupahealth.com and we’ll update the billing for your order.

Patient Consent for Lab Ordering

Authorization

Your Information

Insurance Information

Medicare Information

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Thank You!