Scribd Logo
Upload

Welcome to Scribd!

  • 7 views

    Requisition Form 1

    Uploaded by

    fdhudson92

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Requisition Form 1

    Uploaded by

    fdhudson92
    7 views2 pages

    Original Title

    requisition form 1

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    7 views2 pages

    Requisition Form 1

    Uploaded by

    fdhudson92

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Analyte Health P: (800) 579-3914

    F: (832) 495-4200

    ATTENTION

    QUEST INSTRUCTIONS

    This is a “CLIENT BILL” requisition. Payment or insurance information SHOULD NOT be


    collected from the patient

    A photo ID is not required for testing.

    PATIENT INSTRUCTIONS

    It is required that you bring this form as well as the attached lab form with you to the testing site or
    have them faxed over prior to your arrival

    An appointment is not required.

    To ensure that you will be seen, be sure to sign in upon arrival.

    Do not provide your insurance card to the lab.

    Please disregard the physician and patient signature lines located at the bottom of your requisition.
    These signatures are not required.

    Please do not take supplements that include Biotin for at least 24 hours prior to going into the lab for
    testing. If you have been taking over 30mcg of biotin per day, please wait at least 48 hours after you
    stop taking biotin before visiting the lab.

    Please be sure not to urinate 60 minutes prior to visiting the testing center

    Quest
    ATTENTION
    PLEASE NOTE if you did not purchase this lab test(s) and you DO NOT WANT YOUR CONFIDENTIAL TEST RESULTS
    potentially accessed by the individual who did, please contact our Privacy Office at 1-800-579-3914 or email us at
    [email protected] prior to visiting the lab so that we can update your account accordingly.
    Page # 1 of 1

    Quest Diagnostics Incorporated


    07401519-2C9E95018E

    Client #: 7401519 PSC Hold WS

    KHSS-STD3 For Lab Use Patient Information


    SUITE 242 HUDSON, FRANKLIN
    4611 HARDSCRABBLE ROAD 1667 CLAIRMONT WAY NE
    COLUMBIA, SC 29229 ATLANTA, GA 30329
    866-781-4007(P) 803-753-9800(F) (404) 660-0262

    Collection Date: Time: Pat ID #: 2C9E95018E SSN:

    Lab Reference ID: 2C9E95018E DOB: 12/14/1992 Sex: M

    Ref Physician Provider ID: BOOKS,NORVAL Responsible Party: Bill Type: Client
    Credentials: MD
    NPI: 1215980297 BOOKS,NORVAL

    SSN:
    Relation:
    DOB: Sex:

    Insurance Address:

    Profiles/Tests
    498 - Hepatitis B Surface Antigen with Reflex Confirmation [SERUM]
    512 - Hepatitis A IgM Antibody [SERUM]
    3636 - Herpes Simplex Virus 1 (IgG), Type-Specific Antibody [SERUM]
    3640 - Herpes Simplex Virus 2 (IgG), Type-Specific Antibody [SERUM]
    8472 - Hepatitis C Antibody with Reflex to HCV, RNA, Quantitative, Real-Time PCR [SERUM]
    11363 - Chlamydia/Neisseria gonorrhoeae RNA, TMA, Urogenital [VARIED]
    36126 - RPR (Diagnosis) with Reflex to Titer and Confirmatory Testing [SERUM]
    91431 - HIV-1/2 Antigen and Antibodies, Fourth Generation, with Reflexes [SERUM]

    Signature Line
    _____________ Date
    ____

    10/24/2023

    Ordering provider signature, credentials and date (required by certain payers).

    Barcode # 1 Barcode # 2

    End of Requisition

    Powered by TCPDF (www.tcpdf.org)

    You might also like