LAB REQUISITION FORM

Practice Information Patient Information Practice Name: Patient Name:

Address line 1: Address line 1:

Address line 2: Address line 2:

Phone number: Phone number:

Fax number: Email:

Practice Information

Provider Name: NPI:

LAB ORDER

Please confirm that the following lab orders are correct. Report error or any inconsistencies to [email protected]

Test Name HIV Ag/Ab with Reflex HIV Ag/Ab with Reflex HIV Ag/Ab with Reflex HIV Ag/Ab with Reflex HIV Ag/Ab with Reflex HIV Ag/Ab with Reflex

Test Code: 123456 123456 123456 123456 123456 123456

ICD 10: 123456 123456 123456 123456 123456 123456

Order date:

Requisition number: B0112598113 Show this requisition number to the facility as your order proof

Comment:

Lab Facility Information:

Facility Name: Phone number: Address line 1: Address line 2:

You may go to any other preferred LabCorp locations. The above requisition number is acceptable at all locations

Use this link to view more locations https://www.labcorp.com/labs-and-appointments-advanced-search

You may contact the facility in advance to check if appointments or Walk-in is available

Billing Instructions:

Patient Full Name

Bring acceptable payment method or insurance card with you to the facility

Lab Order Expiration Date: 07/20/2020.

Do not accept or process lab orders after the expiration date

Report Instructions: Please provide the patient with a copy of the report. Fax additional copy to (214) 304-2712