Lab Request Form Medical Staff

Medical Staff

Laboratory Request Form

In order to provide an efficient mobile service request, please complete the following:

Patient Information

Patient (First Middle Last) Name

D.O.B.

Gender

Phone Number

Additional Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Carrier

Insurance Policy No

MRN

Physician Information

Ordering Physician

NPI

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Fax

Referring Entity

Referring Entity Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Fax

Billing

Service Type

Urgency

Fasting

Standing Order

Frequency (If Yes)

Lab Tests

Diagnosis Codes (ICD-10)

Preferred Lab

Lab Account No.

Billing

Bill To

Special Remarks