Maternal Serum Screen Request Form
Download a blank fillable Maternal Serum Screen Request Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Maternal Serum Screen Request Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1University of North Carolina Health Care
EPIC Order # _________________________
Chapel Hill, North Carolina 27514
MATERNAL SERUM REQUEST FORM
McLendon Lab Outreach Program
101 Manning Drive, 1059 East Wing
Chapel Hill, NC 27514
Phone: (984) 974-1414 or (919) 966-2362
FAX: (984) 974-2494 or (919) 843-1425
Date of Sample ____/____/____
UNC MR # _________________________
DOB ____/____/ ____
Patient Name
LAST NAME
FIRST NAME
Address ___________________________________________________________________
County ________________________
City/State _________________________________________________________________
Zip Code _______________________
LMP Date ____/____/____
Ultrasound Date (if done) ____/____/____ Gestational age on day of ultrasound ____weeks____days
Weight ________lbs
Race/Ethnicity
Number of fetuses _______
: □ White
□ Black
□ Hispanic
□ Asian
□ Amer Indian
□ Other
Is this patient an insulin-dependent diabetic (prior to pregnancy)? □ Yes
□ No
Prior pregnancy history of: Down Syndrome? □ Yes □ No
Spina Bifida or Anencephaly? □ Yes □ No
Does the patient smoke? □ Yes □ No
If yes, how many cigarettes per day? _____________
Is this a repeat sample? □ Yes □ No
If yes, specimen code of first sample ____________________
PROVIDER/HEALTH CLINIC INFORMATION (required)
TEST REQUESTED (check one box only)
To be performed between 15 0/7 and 22 6/7 weeks
Clinic/Health Department
_____________________________________________________
□
QUADRUPLE SCREEN (AFP, hCG, uE3, Inhibin-A)
_____________________________________________________
(for second trimester Down syndrome, trisomy 18, neural tube defect (NTD)
_____________________________________________________
and Smith-Lemli-Opitz syndrome testing)
_____________________________________________________
_____________________________________________________
□
AFP (NTD) ONLY
_____________________________________________________
(for patients who had CVS, first trimester screening or 1 positive NTD screen)
Direct Phone number ___________________________________
Provider Printed Name __________________________________
ICD-10 CODE (required): Z34.90 _______ Z34.82 _______
Other ____________
Provider NPI Number ___________________________________
BILLING INFORMATON
□
□
□
□
□
□
Medicaid
Presumptive Medicaid
Indigent
Self Pay
Medicare
Insurance
Medicaid ID# ____________________
Company Name __________________________
Member/Insured ID #______________________
Relationship to insured □ Self □Spouse
ALL OPTIONS OTHER THAN INDIGENT OR SELF PAY REQUIRE
□ Dependent
COPY OF INSURANCE CARD/INFORMATION
CONSENT: I understand that the Quad/AFP screen may not find ALL babies with neural tube defects, Trisomy 18, SLOS or Down
Syndrome. I understand a positive test does not mean my baby has a birth defect. A positive test means the chance for a birth defect is
higher than average and additional tests will be offered. I agree to the testing of my blood sample.
Patient’s signature ___________________________________________________ Date _____/______/______
White copy – Outreach
Yellow copy – Laboratory
Pink copy – Retain for your records
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business