Laboratory Requisition Form printable pdf download

LABORATORY REQUISITION FORM

39 Norman Street

Salem, MA 01970

Please check the type of kit ordered:

Tel: (781) 659-0704

___SIBO

(CPT 82491 & 91065)

(800) 292-9019

___Lactose (CPT 82491 & 91065)

Fax: (781) 659-0705

___Fructose (CPT 82491 & 91065)

Website:

___Sucrose (CPT 82491 & 91065)

E-mail:

___H. Pylori

(CPT 83013)

___C. Difficile (CPT 87449 & 87324)

Louis J. Traficante, Ph.D., Laboratory Director

PATIENT INFORMATION:

Patient__________________________________________

Sex:

Date of Test ______________________

FIrST

LAST

Address____________________________________________ City______________ State_______

Zip ____________

Date of Birth____________

Social Security # (Optional)___________________

Home Telephone _________________

Work Phone________________ Cell Phone_________________

E-Mail ___________________________________

PATIENT PRIMARY INSURANCE AND SUBSCRIBER INFORMATION:

Insurance Company__________________________________________________________ Date of Birth ______________

Insurance ID#___________________________________

Group ID# ______________________________________

Address for Claims____________________________________ City__________________ State_____ Zip __________

SEE INSurANCE CArD

Name of Insured/Subscriber (if different from patient)___________________________ relation to Patient _____________

Address _____________________________________________ City__________________ State_____ Zip __________

Patient Release of Information Authorization:

By signing this requisition Form I authorize the release of any

medical information necessary to my insurance company and the payment of benefits to Commonwealth Laboratories, Inc. for

services received. I also authorize the release of information to the listed physicians and/or individuals named.

Patient Insurance and Test Payment Guidelines:

1. Commonwealth Labs contracts with most National and many Local Insurance Providers. I agree to contact my provider to

inquire whether they contract with Commonwealth and cover the costs of this test.

2. I understand that I am responsible for payment to Commonwealth Labs for any insurance deductable or co-pay charges

applied by my insurance provider.

3. If my insurance provider is not contracted with Commonwealth Labs, I will ask my provider what charges associated

with this test are covered and by what amount by referencing the CPT Code listed above. I understand I am responsible to

pay Commonwealth for test charges which are not paid by my insurance provider.

4. I agree to call Commonwealths customer service department at 1-800-292-9019 to discuss my payment options.

5. I agree to return the test kit to Commonwealth Labs, whether I have taken the test or not, by using the pre-paid self-

addressed uPS label found in each Test Kit.

Signature of Patient or authorized responsible party_____________________________________ Date _______________

(Signature Required or Test Cannot Be Processed)

PHYSICIAN INFORMATION:

Physician Name____________________________________________ NPI#: _____________________________________

Office Phone____________________________________

Office Fax _______________________________________

Address___________________________________________ City_______________ State_______

Zip ___________

ICD-9 Code 1.___________________ 2.___________________ 3.___________________ 4.____________________

Physician Signature____________________________________

WHITE COPY – SEND TO LAB

YELLOW COPY – KEEP ON-SITE

Laboratory Requisition Form

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