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Physician Information

Physician Order not Required

Physicians *

Specimen information

Date of collection *

Time of Collection

Collector Name*

Type of Specimen

Buccal Swab

Prescribed Medications

No Medications Reported

Prescribed

Considered

Please enter at least four keywords

Medication/Drug

Id	Type	Medication/Drug	Action

Take Photo for prescribed medications

Please Select Insurance Type and add Primary Insurance Provider for Testing Options

Testing Option

DIAGNOSIS CODE(S); The ICD-10 codes provided are based on AMA guidelines and are for information purposes only. ICD-10 coding is the sole responsibility of the ordering provider

URINARY

N30.90: Cystitis, unspecified without hematuria

N30.91: Cystitis, unspecified with hematuria

N15.9: Renal tubule-interstitial disease, unspecified

N34.1: Nonspecific urethritis

N34.2: Other urethritis

N39.3: Stress incontinence

DIAGNOSIS CODE(S) |TYPE-IN

Icd10 gem codes

Add

Description *

Icd 10 gem codes	Icd 10 gem code description	Action

Patient Informed Consent

Introduction: This form describes the benefits, risks, and limitations of this test. Read this form carefully before making your decision about testing.

Purpose: The purpose of this test is to determine if you have a urinary tract infection with one of the agents that we test for, and to help your doctor select the best treatment.

How this Test Works: This test detects organisms in your urine and whether or not they display genes for antibiotic resistance.

Test Results: Your test results will be sent to the healthcare provider that ordered the test. Speak with him/her if you would like a copy of the test results. Your healthcare provider is responsible for interpreting the test results and explaining the meaning to you.

Financial Responsibility Statement: I hereby authorize USE MED LAB, and its designees to furnish my designated insurance carrier, health plan or third party administrator
(i) all information I, or someone on my behalf, including my healthcare provider, provides to you in connection with the testing, and
(ii) the test results, as necessary for reimbursement. I also authorize all applicable benefits of my plan to be payable to USAMED LAB or its designees for the services provided.
I understand that I am responsible for any amounts not paid by insurance for reasons including, but not limited to, non-covered or non- authorized services, to the extent permitted by applicable law and/or applicable network provider contracts with insurers.

PHYSICIAN SIGNATURE:

Signature on File or on Order

Use Physician Signature

I authorize USAMED LAB and its affiliated labs to perform testing as directed by this test order form. I understand and hereby acknowledge that: When ordering test for which Medicare or Medicaid reimbursement will be sought, physicians should only order tests that are medically necessary for the diagnosis or treatment of the patient. Read more

PATIENT SIGNATURE:

For non-touch screen devices, the patient needs to type their full name below, and provide a secondary identifier.

Add Signature

By selecting the Add Signature button, I attest that I approve of this digital signature

Signature on File or on Order

I voluntarily consent to the collection and testing of my specimen and certify that the specimen identified on this form is my own, and has not been adulterated in any manner. I certify that the information provided on this form and on the specimen, is accurate. Read more

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

Email:

Patient Ethnicity:

Patient Ethnicity

Race:

Race

Weight (lbs.):

Weight (lbs.)

Height :

Height

Clinical information

Reference ID:

Reference ID

Insurance Type :

Insurance Type

Bill to:

Bill to

Illness/Accident Date

Illness/Accident Date:

Accident Type :

Accident Type

Accident State:

Physician Name:

NPI:

Performing Lab:

Insurance Detail

COLLECTION DETAILS

DIAGNOSTIC CODES

Collected Date:

Date of Collection

Time Of Collection:

Time Of Collection

Collector Name:

Collector Name

Specimen Type:

Report Notes

Medications

Type	Medication/Drug

Allergies

Clinical Information

Known Drug Allergies

PGx Test Order

Physician Signature / Date

Patient Signature / Date

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Self Pay	Commercial Insurance
Medicare	Medicaid
CARES ACT	Client Bill
Other Ins.

Self	Spouse
Dependent	Other

Fever	Chills	Shortness of breath
Difficulty breathing	Fatigue	Muscle and/or body aches
Headache	Loss of taste or smell	Sore throat
Congestion	Runny nose	Nausea
Vomiting	Diarrhea	Other

Daptomycin	Vancomycin
Erythromycin	Clindamycin
Clarithromycin	Azithromycin
Ciprofloxacin	Levofloxacin
Moxifloxacin	Amoxicillin
Amoxicillin/clavulanate	Penicillin
Piperacillin/tazobactam	Cephalexin
Cefuroxime	Ceftriaxone
Cefepime	Ceftazidime
Ceftolozane/tazobactam	Ceftazidime/avibactam
Aztreonam	Imipenem
Imipenem/cilastatin	Meropenem
Linezolid	Metronidazole
Nitrofurantoin	Fosfomycin
Tetracycline	Doxycycline
Tigecycline	Trimethoprim/sulfamethoxazole
Gentamicin	Amikacin
Tobramycin	Fluconazole
Rifampin	Neomycin
First generation cephalosporins	Second generation cephalosporins
Third generation cephalosporins	Fourth generation cephalosporins
Fifth generation cephalosporins	Carbapenems
Glycopeptides	Lipopeptides
Sulfonamides	Trimethoprim
Quinolones	Azoles
Aminoglycosides	Tetracyclines
Lincosamides	Oxazolidinones
Macrolides	Nitrofurans
Polymyxins

Hispanic or Latino	Not Hispanic or Latino
Other or Unknown

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PHYSICIAN SIGNATURE:

PATIENT SIGNATURE: