Patient Form

Patient Information

Biling Information

When ordering tests for which Medicare reimbursement will be sought, physicians (or other individuals authorized by law to order tests) should only order tests that are medically necessary for the diagnosis or treatment of a patient, rather than for screening purposes.

Medical Tests Information

It is the ordering party's responsibility to order only those tests medically necessary for the diagnosis and treatment or the patient.

Toxicology Testing

* An inconsistent result may be recorded on a report if a complete medication list is not provided.

Wellness Panels

Panels

* G = Grey ____ L = Lavender ____ LB = Lt Blue ____ R = Red ____ S = SST ____ GSW = G.I. Swab ____ RSW = Respiratory Swab ____ U = Urine Cup

Individual Tests

* G = Grey ____ L = Lavender ____ LB = Lt Blue ____ R = Red ____ S = SST ____ GSW = G.I. Swab ____ RSW = Respiratory Swab ____ U = Urine Cup