2623 South Seacrest Blvd #206
Boynton Beach, FL 33435
Home Visit Request Form
NEED HELP WITH ICD 10 CODES?
Visit us online at www.apexlabinc.com
Click on the “Help with ICD-10 Codes” link
Search common ICD9- to ICD-10 translaons
Search ICD-10 codes by name
Find valid ICD-10 codes for Limited Coverage Tests
(PT/INR, Lipids, Thyroid Studies etc.)
THIS ORDER IS FOR A
(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
Ordering Provider(s) Informaon:
Agency Name: Account#:
Physician Last Name: First Name:
ity: State: Zip:
CC: Results to addional Doctor/Pharmacy: (Name and Fax#)
Paent SSN#: DOB:
Paent Last Name: First Name: Sex:
City: State: Zip:
Alternate Contact: (Name and Phone#)
Medicare #: Bill Agency:
Other: Bill Paent:
Policy Holder Name and Relaonship (If not Paent):
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).
One Time Only
Weekly _____________x 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.
**Helpful Hints from Apex**
Schedule visits online and view results by logging into your account at:
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
Diagnosis and/or ICD-10 Code