Employee Multiphasic

Informed Consent

I allow the employees or agents of Mon Health Medical Center to draw a sample of my blood for testing in the Multiphasic Health Screening and/or Prostate Specific Antigen (PSA) and/or Thyroid Screening and/or A1C Screening. I understand that these tests are for screening only and if there are abnormalities, it will be my sole responsibility to seek further evaluation and treatment as recommended. I understand it is not uncommon to experience some bruising (hematoma) at the site where the needle entered my arm for the blood specimen collection. Via my registered consent, I release Mon Health Medical Center, Monongalia Health System, Inc., their respective directors, officers, agents, and employees from liability for injury arising from this blood draw.

To avoid bruising, please follow the instructions below:

Leave the pressure bandage (band-aid) intact for at least ½ hour (1 hour if taking blood thinners).

Avoid heavy lifting or undue strain on involved arm for at least three hours. (Ex. Carry your purse on the other arm)

Apply ice if there is stinging, burning or bruising at the venipuncture site.

Financial Responsibility

I hereby agree to be responsible for and guarantee the payment of charges for all services rendered. I understand that I am financially responsible for all charges not covered by my insurance carrier.

Insurance Coverage/Assignment of Benefits

I hereby authorize payment directly to the Hospital. I request that payment of authorized benefits be made on my behalf.

Notice of Privacy

I understand that the Monongalia Health System Privacy Notice that describes how my health information may be used for the purpose of treatment and/or payment of healthcare operations will be available to me at the site of my blood draw.

If you need to reschedule or miss your desired multiphasic day, please sign up again for your new desired day.

Results will be available via the MyMonHealth online portal. Results will not be mailed. If you don’t have a MyMonHealth account, click here to register.

Please add your desired screening day to your calendar. You will not receive an appointment confirmation letter for these events. Don't forget to fast 12 hours before your screening!