2623 South Seacrest Blvd #206
Boynton Beach, FL 33435
Home Visit Request Form
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Click on the “Help with ICD-10 Codes” link
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Find valid ICD-10 codes for Limited Coverage Tests
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THIS ORDER IS FOR A
MEDICALLY NECESSARY
HOME VISIT
(See 1 to Right)
If the home visit is NOT Medically
Necessary, check this box to
indicate that the paent should
be billed for the home visit
Phone: 561-279-1852
Fax: 561-279-1853
Ordering Provider(s) Informaon:
Agency Name: Account#:
Physician Last Name: First Name:
Address:
Suite:
C
ity: State: Zip:
Phone: Fax:
NPI:
CC: Results to addional Doctor/Pharmacy: (Name and Fax#)
Paent Demographics:
Paent SSN#: DOB:
Paent Last Name: First Name: Sex:
Address:
Apt:
City: State: Zip:
Home Phone:
Cell Phone:
Alternate Contact: (Name and Phone#)
Insurance Informaon:
Medicare #: Bill Agency:
Other: Bill Paent:
Plan:
Member ID:
Policy Holder Name and Relaonship (If not Paent):
Rev 8.2015
Test Informaon:
1. Medically Necessary Home Visits – By sending this request, the ordering physician is cerfying that the paent is homebound and that
both the home visit and the lab test(s) that are being ordered are medically necessary
2. Paent Billable Home Visit – For the paents that are not categorized as homebound, but request a phlebotomist come to their home,
Apex Laboratory, Inc. will bill them $25.00 (subject to change) for the home visit and charge their insurance carrier for the draw and the test(s).
3. ICD-9/ICD-10 Diagnosis Codes – Medicare requires a diagnosis for every test ordered and a specic diagnosis for certain tests categorized
as “Medicare Limited Coverage Tests”. Without an appropriate diagnosis code (a narrave is acceptable), Medicare will not pay for the
test(s), and we will not schedule these test(s).
Frequency:
One Time Only
Weekly _____________x Weekly
Bi-Weekly
(Every Other Week)
Monthly Every __________ Month(s)
Start Date _____________ End Date _____________(Can’t exceed 6 months)
*End date required for standing orders. If end date not indicated, orders will be placed for 6 months.
Orders can be cancelled or updated at anyme by contacng Apex.
Fasng?: Yes No
Please Note: Fasng should only be ordered if indicated by ordering physician.
If paent is not fasng upon arrival, the visit will be rescheduled next day.
Days of Week: Mon. Tues. Wed. Thurs. Fri.
Male:
Female:
________/________/_________
**Helpful Hints from Apex**
Schedule visits online and view results by logging into your account at:
www.apexlabinc.com
To prevent delays in scheduling please remember the following:
Be sure that this form is COMPLETELY lled out
A diagnosis is REQUIRED for all requested test(s)
Fax orders no later than 5pm the day before the visit is needed
Include DOSE TIME for all trough levels. Visit will be scheduled prior to dose
Test(s):
Diagnosis and/or ICD-10 Code
1
2
3
5
6
7
8
9
10
Misc.:
