Licensed Healthcare Provider Authorization Form
Download a blank fillable Licensed Healthcare Provider Authorization 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 Licensed Healthcare Provider Authorization 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
1LICENSED HEALTHCARE PROVIDER AUTHORIZATION FORM
MUST BE COMPLETED BY THE AUTHORIZING/ORDERING PHYSICIAN
Physician authorization for test order—fax to: 310.552.1940
ICD-9/DX Code: 729.1-Fibromyalgia
PATIENT INFORMATION
Prefix
Last Name
First Name
Street Address
City
State
Zip Code
Phone
Fax
Email
Test Requested (please check):
FM/a
—The FM Test
®
PHYSICIAN INFORMATION
DEGREE
Last Name
First Name
MD
DO
NP
PA-C
ND
DC
Street Address
City
State
Zip Code
Phone
Fax
Email
Medications: Certain drugs, medications and supplements can interfere with the test process. These include steroids, anti-
cancer drugs, anti-organ transplant drugs and any drugs that could affect the body’s immune system, including some that
are available over-the counter. Does your patient take any of these drugs? Please check only one box. If YES, please list the
medications below.
NO
YES
List medications here:
Ordering Physician’s Signature
Date
EpicGenetics, Inc.
For Laboratory Use Only
ADVERTISEMENT
0 votes
Related Articles
Related forms
Parent Consent And Licensed Healthcare Provider Authorization For Diabetes Management In School And School Sponsored Events Form
Legal
Healthcare Provider Screening Form - State Employees' Health Insurance Plan - State Employees' Insurance Board - Alabama
Legal
Parent Consent And Authorized Healthcare Provider Authorization For Management Of Anaphylaxis At School And School-sponsored Events - Form
Legal
Healthcare Provider Office Information Form - U.s. Department Of Health And Human Services - 2015
Legal
Related Categories
Parent category: Business