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Patient Information

Patients *

First Name *

Last Name *

Patient DOB *

Month: Day: Year:

Address 1 *

Address 2

City *

State *

Zip Code *

Email

Phone No

Gender *

Male

Female

Is this a medicare patient ? *

No	Medicare
Medicaid	Tricare
Workers Comp

Is this a wellness patient ? *

No

Yes

Injury Date

Month: Day: Year:

Employer

Claim #

Physician Information

Physicians *

Specimen information

Date of collection *

Time of Collection *

Icd10 gem codes

Add

Description *

Icd 10 gem codes	Icd 10 gem code description	Action

PATIENT

PROVIDER

First Name:

First Name

Last Name:

Last Name

DOB:

DOB

Gender:

Gender

Address:

Address

Address 2:

Address2

City:

City

State:

State

Zip Code:

Zip Code

Phone No:

Phone No

Is this a medicare patient :

Is this a medicare patient

Is this a wellness patient :

Is this a wellness patient

Injury Date

Injury Date:

Employer :

Employer

Claim # :

Claim #:

Bill to:

Bill to

Relationship to insured:

Integrated Pain Clinic

Provider Name:

Provider Name

Insurance Provider:

Policy Holder DOB:

Policy ID:

Group Id:

Relationship to insured:

Secondary Insurance:

Policy ID:

Group Id:

Physician Name:

Physician Name

NPI:

NPI

COLLECTION DETAILS

DIAGNOSTIC CODES

Collected Date:

Date of Collection

Time Of Collection:

Time Of Collection

REQUESTED TESTS

Metabolic Health

Heart Health

Hormone Health

Allergy Testing

Toxicology Panel

LC/MS/MS Panel

EIA Panel

Additional Test

Genetic Testing (DNA)

Physician Signature / Date

Patient Signature / Date

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