Free Lab Work Request Form

Charitable Organization Name *

Contact Name *

Email *

Address *

Address Line 2

City *

State *

Zip *

Phone (area code included) *

List the test(s) requested and the annual number of each test(s) your Health Center will send to DLO *

Is your Health Center a Federally Qualified health Center (FQHC)? If "no", please complete the questions below. *

Does your Health Center operate through receipt of charitable contributions only?

Do all of the physicians and other medical professionals who work at your Health Center volunteer all of their services free of charge?

If the answer to the above question is "No", do all of the physicians and other persons who work at the Health Center provide their services free of charge to those patients who the Health Center qualifies as being indigent, based on patient income of less than 200% of the Federal Poverty Guidelines, and by obtaining financial information from the patients to validate their qualification for treatment as an indigent patient?

If your Health Center does not provide free health services to all of its patients, does the Health Center provide free health services to certain patients which the Health Center qualifies as being indigent?

Does your Health Center charge any patients for lab work? *

Does your Health Center bill insurance for lab work on any of your patients? *

Provide a description of your Health Center and the nature of services provided to indigent patients *

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