Form Llk0001 - Test Request Form
ADVERTISEMENT
1
2TEST REQUEST FORM
Patient Last Name, First Name
Physician Last Name, First Name
Date of Birth
Gender (M/F)
Physician Street Address
Last 4 Digits of SSN
City, State, Zip Code
MRN # (will display on report)
Offi ce/Physician Phone #
E-mail (optional)
Physician/Authorized Signature
Date
ALL PATIENT INFORMATION MUST BE COMPLETED
ALL PHYSICIAN INFORMATION MUST BE COMPLETED
Diagnosis:
N20.0 Kidney Stones
Other
Diagnosis/Signs/Symptoms in ICD-CM format in effect at Date of Service (Highest Specifi city Required)
Cystine Urine Panels:
Choose only
(for patients with known cystinuria)
Kidney Stone Urine Panels:
one panel
One, 24-hour collection
Two, 24-hour collections
One, 24-hour collection
All tests will be performed on each 24-hour urine collection.
TEST
CPT CODE
TEST
CPT CODE
Two, 24-hour collections
Calcium ...................... 82340
Sodium ...................... 84300
Creatinine .................. 82570
Urea Nitrogen ............ 84540
All tests will be performed on each 24-hour urine collection.
Citrate ........................ 82507
Quantitative Cystine .. 82131
TEST
CPT CODE
TEST
CPT CODE
Phosphorus ............... 84105
Timed Collection ........ 81050
Calcium ...................... 82340
Chloride ..................... 82436
pH .............................. 83986
Creatinine .................. 82570
Ammonium ................ 82140
Citrate ........................ 82507
Magnesium ................ 83735
Serum/Blood Collection
Phosphorus ............... 84105
Potassium .................. 84133
pH .............................. 83986
Uric Acid .................... 84560
Location:
LabCorp Patient Service Center
Sodium ...................... 84300
Sulfate ....................... 84392
Physician’s Offi ce or Hospital
Urea Nitrogen ............ 84540
Qualitative Cystine** ... 82615
All tests will be performed per blood draw
Oxalate ...................... 83945
Timed Collection ........ 81050
TEST
CPT CODE
TEST
CPT CODE
Calcium ...................... 82310
Chloride ..................... 82435
Creatinine .................. 82565
Potassium .................. 84132
Phosphorus ............... 84100
Sodium ....................... 84295
Magnesium ................ 83735
Uric Acid ..................... 84550
**Qualitative Cystine is a one-time test done routinely
Carbon Dioxide .......... 82374
on all new patients
Special Handling:
Spanish Speaking
Delay Shipment of At-Home kit Until:______/______/______
Obtain your At-Home kit using these options (Choose one)
ONLINE
SHIP TO:
24 Hours/Day
ADDRESS
STREET
FAX
to 1-312-243-3297
CITY
STATE
ZIP CODE
Shipping address required for faxed orders
PHONE #
CALL
1-800-338-4333
All faxed orders will be processed next business day.
M - F 7:30AM - 6:00PM CT
RETURN THIS FORM TO LITHOLINK
WITH YOUR COMPLETED URINE
For Litholink Use ONLY
SAMPLES
LLK0001 (Rev. 5/2016)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business