Note: All information with a red asterisk ( * ) must be completed

Patient Information
Month: Day: Year:
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
DIAGNOSIS CODE(S) |TYPE-IN
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Physician Information
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PHYSICIAN SIGNATURE:

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

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

Signature on Paper Requisition
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I am authorized to order laboratory tests and hereby order the tests indicated below. I confirm these test(s) are medically necessary for the treatment of the patient. I supplied accurate and true information on this form. I am aware information has been supplied to the patient about drug testing and that the patient has consented to the testing through his/her signature on this form. I understand that it is my responsibility to document medical necessity for testing in the patient record and to provide a copy of the same to Labs upon request. 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 Paper Requisition
I supplied accurate and true information with this form. If I supplied insurance information, I authorize payment of my insurance benefits directly to Labs. I authorize Labs to be my Designated Representative and to appeal any denial of health benefits. I understand Labs may be out of network with my plan, and I accept responsibility for paying to Labs any amounts my insurer determines are my responsibility after calculating deductibles, co-payments and co-insurance due under my policy. I understand I am legally responsible for sending Labs any money received from my health insurance company for performance of this laboratory test. I also allow the release of medical information necessary to process this claim. Read more
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DIAGNOSTIC CODES
Medical Necessity
Infectious Disease Test Order
 
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Patient Signature / Date