Fillable Sidebar%5CA1426 COVID-19 Patient Order Form 10-21-20

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Sidebar%5CA1426 COVID-19 Patient Order Form 10-21-20

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Laboratory Requisition
Patient Testing COVID-19
CLINICAL LABORATORIES
Phone: 513.636.7355
Fax: 513.636.3918
www.cincinnatichildrens.org/labs
Practice Name:
Address:
A1426
HIC 10/20
*DTA1284*
*DTA1284*
Please reference the Test Directory/Index for tests not listed: www.cincinnatichildrens.org/labs
PATIENT INFORMATION
Patient Name (Last, First): , Date of Birth: / /
Address: Phone: ( )
Medical Record Number: Collection Date: / / Collection Time: Priority: Stat Routine
Dx Description or ICD – Code (REQUIRED): Bill To: Self Pay Insurance Client (Client code: )
BILLING INFORMATION
Insurance:
Ordering Provider Name & Credentials (Printed):
Subscriber ID:
Group No.:
Phone: ( )
Fax: ( )
Address:
City/State/ZIP:
Clinician Signature (REQUIRED)
Date
Time
Phone: ( )
Subscriber DOB:
MEDICAL NECESSITY REGULATIONS: At the government’s request, the Clinical Laboratories would like to remind all
physicians that when ordering tests expected to be paid under federal health care programs, such as Medicare and
Medicaid, the tests must meet the following conditions: (1) included as covered services, (2) reasonable, (3) medically
necessary for the treatment and diagnosis of the patient and (4) not for screening purposes.
Subscriber Name/Rel.:
PATIENT DEMOGRAPHICS
Race:
Black or African American
White
Hispanic/Latino
Asian
American Indian
Middle Eastern
Alaska Native
Native Hawaiian and Other Pacific Islander
Preferred Category Not Available
Refused
Unknown
Ethnicity:
Hispanic
Non-Hispanic
Unknown
Refused
Gender:
Male
Female
If female: Currently pregnant?
No
Yes
Unknown
Is this the first COVID test?
No
Yes
Unknown
Is the patient in a group care facility?
No
Yes
Unknown
(Group home, foster care, homeless shelter, orphanage, detention facility, psychiatric facility, board and care home, substance abuse center)
Is the patient symptomatic?
No
Yes
If yes, when did symptoms start? / /
TESTS
INSTRUCTIONS:
COVID-19 Test Molecular
COVID-19 Ab Total Qualitative
COVID-19 IgG Qualitative, Reflex to Quantitative
COVID-19 IgG Qualitative, Reflex to Quantitative, IgA and IgM Qualitative
1. Complete the registration legibly with all
information.
2. Use the swab provided in the test kit to collect
a nasopharyngeal sample.
3. Label sample with the patient’s full legal name
and date of birth.
4. Send labeled sample and this requisition to
the laboratory.
5. Once in the lab, send to lab registration team.
Name of person completing form: Phone #:
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Sidebar%5CA1426 COVID-19 Patient Order Form 10-21-20

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Completed 16 November 2021

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