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HIPAA (Health Insurance Portability and Accountability Act

THIS NOTICE DESRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS IT.    


Your Rights

Access your records, request corrections, request confidential communication, limit sharing, and obtain a list of disclosures.


Uses & Disclosures

We use your information for treatment, payment, and healthcare operations, and may disclose it as required by law, public safety, or DOT/drug testing compliance.



Our Responsibilities

We protect your PHI, notify you of breaches, and follow this notice.



Contact Information

Twin Pillars Diagnostics LLC

Phone: (478)236-2243

Fax: (478)236-2476

Email: Twinpillarsd@gmail.com

EFFECTIVE DATE: FEBRUARY 10, 2026

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Welcome to Twin Pillars Diagnostics.

Complete the secure form below to let our staff know you have arrived.

Walk-ins are welcome. Scheduled appointments may receive priority.

Financial Responsibility Agreement

1. Responsibility for Payment

I understand and agree that I am financially responsible for all services provided by Twin Pillars Diagnostics LLC, regardless of insurance coverage, employer arrangements, or third-party billing.


2. Payment Due at Time of Service

Payment is due at the time services are rendered, unless prior arrangements have been made. Accepted payment methods may include credit/debit cards, cash, or approved electronic payments.


3. No Refund Policy

I understand that all services are non-refundable once performed, including but not limited to:


  • Drug and alcohol testing

  • DNA testing services

  • Phlebotomy services

  • Fingerprinting services


4. Employer / Third-Party Billing

If services are being paid by an employer or third party:


  • I understand that I am ultimately responsible for payment if the third party does not pay

  • I authorize Twin Pillars Diagnostics LLC to bill the third party on my behalf (if applicable)


5. Missed Appointment / Cancellation Policy

I understand that:


  • A no-show or late cancellation fee of $25 apply

  • Late arrival may result in rescheduling and additional fees


6. Additional Fees

I understand that additional fees may apply for:


  • Re-collections due to insufficient samples

  • Expedited or rush services

  • After-hours or mobile services (if applicable)


7. Charge Authorization

I authorize Twin Pillars Diagnostics LLC to charge my provided payment method for all services rendered, including any applicable fees.


8. Collections & Non-Payment

If payment is not made:


  • My account may be sent to collections

  • I may be responsible for additional collection costs, fees, and legal expenses as permitted by law


9. Acknowledgment & Agreement

By signing below, I acknowledge that I have read, understand, and agree to the terms of this Financial Responsibility Agreement.

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Release Authorization

1. Authorization

I hereby authorize Twin Pillars Diagnostics LLC to collect, handle, and release my specimen(s) and related personal and health information to designated reference laboratory partners for the purpose of processing, analysis, and reporting of test results.


2. Scope of Information Released

This authorization includes, but is not limited to:

  • Blood, urine, saliva, or other collected specimens

  • Identification information necessary for testing

  • Test orders and related documentation

  • Results reporting coordination between Twin Pillars Diagnostics LLC and the reference laboratory


3. Purpose

I understand that this disclosure is necessary to:

  • Perform laboratory testing services

  • Process and analyze collected specimens

  • Generate and return test results


4. Acknowledgment of Third-Party Handling

I understand that:

  • Reference laboratories operate as separate entities

  • My specimen and information will be handled in accordance with applicable laws and laboratory policies

  • Once released, information will be subject to the privacy practices of the receiving laboratory


5. No Guarantee of Results or Timelines

I acknowledge that Twin Pillars Diagnostics LLC does not control the testing process once specimens are released and makes no guarantees regarding turnaround times or results.


6. Revocation

I understand that I may revoke this authorization in writing at any time; however, revocation will not apply to information already released or specimens already sent for testing.


7. Voluntary Consent

I certify that I am signing this authorization voluntarily


IMPORTANT DISCLOSURE

Twin Pillars Diagnostics LLC is a fingerprint collection service only. We do not process background checks and are not affiliated with any government agency, including the Federal Bureau of Investigation.

It is the client’s responsibility to provide the correct ORI number and reason for fingerprinting. Twin Pillars Diagnostics LLC is not responsible for rejected fingerprint cards due to incorrect information, agency requirements, or processing errors outside of our control.

Refunds will not be issued for rejected fingerprint cards once services have been completed.


CONSENT & ACKNOWLEDGMENT

By signing below, I confirm that:

- The information I provided is accurate

- I understand Twin Pillars Diagnostics LLC only collects fingerprints

- I accept responsibility for verifying all agency requirements


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Consent To Services

1. Consent to Services

I, the patient hereby consent to receive services provided Twin Pillars Diagnostics LLC. I understand that may include but are not limited to:  phlebotomy, drug screening, breath alcohol testing, DNA testing, fingerprinting, and background checks.   



2. Acknowledgment of Risks

I understand that certain services may involve minor risks, including but not limited to:


  • Bruising, bleeding, or discomfort from blood draws

  • Dizziness or fainting

  • Temporary skin irritation

  • Inconclusive or delayed test results


I acknowledge that no guarantees have been made regarding results or outcomes.


3. Authorization to Perform ServicesI authorize trained personnel of Twin Pillars Diagnostics LLC to perform the requested services in accordance with standard procedures and protocols.


4. Information Accuracy

I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that inaccurate information may affect test results.


5. No Medical Treatment or Diagnosis

I understand that Twin Pillars Diagnostics LLC provides collection and screening services only and does not diagnose, treat, or provide medical advice.


6. Release of Liability

To the fullest extent permitted by law, I release and hold harmless Twin Pillars Diagnostics LLC, its owners, employees, and affiliates from any liability arising from services performed, except in cases of gross negligence or willful misconduct.


7. Financial Responsibility

I agree to be financially responsible for all services provided. I understand that fees are due at the time of service unless otherwise arranged.


8. Voluntary Consent

I certify that I am at least 18 years old (or the legal guardian of the patient) and that I am signing this consent voluntarily without coercion.

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