Get Acrobat Dch 0696

Filling out the Acrobat Dch 0696 form accurately is essential for submitting a blood lead test requisition effectively. This guide will provide you with clear, step-by-step instructions to help you complete the form online with confidence.

Follow the steps to complete the Acrobat Dch 0696 form online.

1. Press the ‘Get Form’ button to access the Acrobat Dch 0696 form and open it in your chosen online editor.
2. In the submitter information section, enter your full name, address, city, state, and zip code clearly. Include the submitter clinic code and your telephone and fax numbers.
3. Record the name of the physician or authorized provider who ordered the test, and ensure to include their National Provider Identifier.
4. Choose the appropriate ICD-10 diagnosis code by checking the relevant box. If selecting 'other', provide the required code.
5. If desired, add an additional clinic code for mailing a copy of the results.
6. Complete the patient information section by entering the last name, first name, mailing address, birth date, and phone number of the patient.
7. Record the parent or guardian's name, and select the appropriate options for gender, race, and ethnicity.
8. In the specimen information section, include your Tube/Submitter ID, the collection date in MM-DD-YY format, and collection time in military format.
9. Indicate the specimen type by checking the relevant box.
10. Fill out the Medicaid information or private insurance information as necessary, ensuring all details are accurate to avoid billing issues.
11. Finally, review all entered information for accuracy and completeness. Save your changes, and upon completion, you can download, print, or share the form.

Start filling out your Acrobat Dch 0696 form online today for effective submission.