Clinical Chemistry Requisitions
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2WITH A HEARTBEAT
B00001
DELIVERING LABS
STAT
B00001
B00001
B00001
COLLECTION
DATE
PHONE:
Contact number required if STAT selected
:
COLLECTION
TIME
AM PM
Patient Name
Patient Name
Patient Name
B00001
B00001
B00001
Patient Name
Patient Name
Patient Name
1
REQUESTING PHYSICIAN • PROVIDER • LAB • INSTITUTION
FRONT & BACK
REQUIRED:
ENCLOSE A COPY OF THE
OF PATIENT’S INSURANCE CARD(S)
2
3
PATIENT INFORMATION
PRIMARY INSURANCE INFORMATION
INSURANCE:
SELF PAY:
CLIENT BILL:
Last: ____________________________ First: ___________________________ Middle Initial: _______
Insurance Carrier:
_____________________________________________________
S. S. # : ___________________________ D.O.B. ______ / ______ / _________
SEX:
M
F
Member ID # :
Group ID #:
__________________________
__________________ _ _
Address: ____________________________________________________________
See Attached
Name of Insured Person:
_______________________________________________
City: ____________________________ State: _____________ Zip Code: ________________________
Relationship to Patient (if applicable):
__________________________________
Phone: (____) ________ - ____ _______ Email: _____________________________________________ _ ___
4
ICD-10 DIAGNOSIS CODES
The information I have provided on this form is accurate. I authorize Castle Medical to release the results of this testing to the treating physician
or facility. I hereby authorize my insurance or other payment benefits to be paid directly to Castle Medical for services I received. I acknowledge
that Castle Medical may be an out-of-network provider with my insurer. I am also aware that in some circumstances my insurer might send the payment
directly to me. I agree to endorse the insurance check and forward to Castle Medical within fifteen days of receipt. I acknowledge that I am
responsible for all co-pays and deductibles not covered by insurance or other payors.
Patient Signature:
Date:
5
AVAILABLE TESTS
PLEASE VISIT FOR MORE TEST INFORMATION
PLEASE SEE REVERSE SIDE FOR
PANEL COMPONENTS
AND
ABN REQUIREMENTS
(PLEASE NOTE: ALL
TEST CODES CIRCLED IN RED
MAY BE SUBJECT TO
ABN
REQUIREMENTS)
x ORGAN/DISEASE PANELS
x
x
x MOLECULAR DIAGNOSTICS*
INDIVIDUAL TESTS | CONTINUED
INDIVIDUAL TESTS | CONTINUED
80048
GEL
82550
GEL
83970
LAV
Basic Metabolic Panel (8)
Creatinine Kinase
Parathyroid Hormone (PTH), Intact
RP09
RL55
1067
Precert. Authorization #:______________________
Comp. Metabolic Panel (14)
80053
GEL
DHEA-S
82627
RED
Partial Thromboplastin Time (PTT)
85730
BLU
BRCA Panel
SEE BACK
RP01
RB02
GP10
RL96
CHEMO DME Panel
Comp. Liver Panel (15)
GEL
Estradiol
82670
GEL
Reverse T3
84482
GEL
SEE BACK
GP02
RP17
SEE BACK
RL99
RH09
Electrolyte Panel (4)
80051
GEL
Estriol
82677
GEL
Rheumatoid Factor
86431
GEL
CORE DME Panel
SEE BACK
RP39
RL48
RL76
GP07
Estrogen Panel (4)
GEL
Estrogen, Total
82672
GEL
SHBG
84270
GEL
Factor II
81240
RP11
RL93
GP11
SEE BACK
RL97
Hepatic Function Panel (7)
80076
GEL
Estrone
82679
GEL
Sed Rate
(ESR)
85652
LAV
Factor V Leiden
81241
RP18
RL33
GP12
RL81
Iron Panel (4)
GEL
Ferritin
T3, Free
MTHFR
81291
82728
GEL
84481
GEL
RP31
1057
RL88
GP04
SEE BACK
Lipid Panel (5)
GEL
Warfarin Panel
SEE BACK
80061
Folate (Folic Acid)
82746
GEL
T3, Total
84480
GEL
RP03
RH10
GP03
RB09
T3 Uptake
Prenatal Screen Panel (4)
GEL
Follicle-stimulating Hormone (FSH)
83001
GEL
84479
GEL
RH18
RP45
RL83
SEE BACK
x INFECTIOUS DISEASE
Renal Function Panel (11)
80069
GEL
Gamma-Glutamyl Transferase (GGT)
82977
GEL
T4, Free
84439
GEL
RP29
RL42
RL24
CT/NG
SEE BACK
MD01
GEL
84436
Testicular Function Panel (7)
GEL
82947
T4, Total
GEL
RP43
Glucose, Serum
RL90
RL01
SEE BACK
Hepatitis A/B/C Cascade
SEE BACK
MD05
Thyroid Panel (5)
GEL
Glucose, 1 Hour Tolerance
82950
GEL
Testosterone, Free
84402
GEL
RP20
1082
RL95
SEE BACK
HSV 1 & 2 and VZV
SEE BACK
MD08
x
Testosterone, Total
HEMATOLOGY
Glucose, 3 Hour Tolerance
82951
GEL
84403
GEL
1083
RL92
HIV 1/O/2 Cascade
SEE BACK
MD10
85025
LAV
hCG, beta, Quantitative
84702
GEL
Thyroid Peroxidase Ab. (TPO)
86376
GEL
CBC with Differential and PLT
RP04
RL89
RH14
MMR Immunity Panel
SEE BACK
MD06
LAV
CBC with Retics
Haptoglobin
83010
GEL
Transferrin
84466
GEL
85045
RP41
1062
1121
Respiratory Viral Panel
SEE BACK
MD07
LAV
CBC without Differential
85027
Hemoglobin A1c
83036
LAV
Triglycerides
84478
GEL
RP40
RL20
RL82
STD Screening Panel
SEE BACK
MD09
x
INDIVIDUAL TESTS | A-Z
HDL Cholesterol
83718
GEL
Thyroid-stimulating Hormone (TSH)
84443
GEL
RL21
RL18
WELLNESS PANEL
Albumin
GEL
Homocysteine
83090
LAV
TSH with Reflex T4, Free
GEL
82040
RL11
S049
RP34
SEE BACK
Anti-Aging Panel (F)
SEE BACK
Alkaline Phosphatase (ALP)
84075
GEL
IgA
82784
GEL
Uric Acid
84550
GEL
RP48
RL14
1063
RL43
Alpha-1-Acid Glycoprotein
GEL
IgE, Total
82785
GEL
Vitamin B
82607
Cardiac Health Panel
SEE BACK
83883
GEL
1039
1118
RB08
RP49
12
Alpha-Antitrypsin
82103
GEL
IgG
82784
GEL
Vitamin D, 25 OH, LC/MS/MS
82306
GEL
Comp. Wellness Panel (M)
SEE BACK
1011
1064
S057
RP50
Alpha-Fetoprotein (AFP)
82105
GEL
IgM
82784
GEL
x
1009
1065
THERAPEUTIC DRUG MONITORING
Comp. Wellness Panel (F)
SEE BACK
RP47
(ALT)
84460
GEL
86336
GEL
Inhibin A
Digoxin
80162
RED
RL16
Alanine Aminotransferase
1066
(SGOT)
1052
ADDITIONAL TESTS:
Ammonia
Insulin
Gentamicin, Peak
82140
LAV
83525
GEL
80170
RED
1014
1125
1059
Amylase
82150
GEL
Iron
83540
GEL
Gentamicin, Trough
80170
RED
1100
1060
RL74
Antinuclear Antibodies (ANA)
86038
GEL
Lactate Dehydrogenase (LDH)
83615
GEL
Lithium
80178
RED
R001
1072
RL54
Apolipoprotein A-1
82172
GEL
Lactic Acid
83605
GRY
Phenytoin
RED
1017
80185
1069
1108
Apolipoprotein B
82172
LDL Cholesterol
GEL
Theophylline
GEL
83721
80198
RED
1018
RL22
1116
(AST)
Luteinizing Hormone (LH)
GEL
Tobramycin, Peak
80200
84450
GEL
83002
RED
RL15
Aspartate Aminotransferase
RL84
1117
(SGOT)
Bilirubin, Total
82247
Lipase
GEL
Tobramycin, Trough
GEL
83690
80200
RED
RL17
1071
1081
Bilirubin, Direct
Magnesium
GEL
82248
GEL
83735
Valproic Acid, Free
80165
RED
RL40
1074
RB05
B-Type Natriuretic Peptide (BNP)
83880
LAV
Phosphorous
84100
GEL
Valproic Acid, Total
RED
1122
RL39
80164
RB04
Potassium
84132
Blood Urea Nitrogen (BUN)
84520
GEL
GEL
Vancomycin, Peak
80202
RED
RL02
RL06
1127
C-Reactive Protein (CRP)
Prealbumin
86140
GEL
84134
GEL
Vancomycin, Trough
80202
RED
RL80
1109
1135
82310
GEL
Progesterone
Calcium
84144
GEL
x
URINALYSIS
RL09
RL67
Carcinoembryonic Antigen (CEA)
GEL
Prolactin
84146
GEL
82378
Pregnancy Screen, Urine, Qual.
84703
CUP
1030
RL85
P129
Cholesterol, Total
82465
GEL
84155
GEL
Urinalysis, Dipstick
Protein, Total
81002
CUP
RL19
RL10
UA01
GEL
Prostate-specific Antigen (PSA)
GEL
Urinalysis w. Reflex to Microscopy
Cortisol
82533
81000
CUP
RL87
RP42
UA02
SEE BACK
GEL
85610
Creatinine
82565
PT/INR
BLU
Urine Culture & Sensitivity
87086
UCT
RL03
RP32
R002
* For most common Molecular Diagnostic tests a Precertification Authorization Number is required.
_____________________________
____ ____
/
/___________
Physician Signature:
Date:
V1.0
I hereby authorize the laboratory tests selected above and acknowledge that the test(s) ordered are medically necessary.
castle - white copy | physician - yellow copy | patient - pink copy
CASTLE MEDICAL, LLC
•
5700 Highlands Parkway, Suite 100, Smyrna, Georgia 30082 •
Phone:
678.486.7340
•
Fax:
678.486.7350
•
Email:
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