Get Request For Respiratory/influenza Testing - Illinois Department Of ... - Idph State Il

Completing the Request For Respiratory/Influenza Testing form from the Illinois Department of Public Health is a crucial step for those needing respiratory or influenza testing. This guide will walk you through each section of the form, ensuring you understand how to fill it out accurately and effectively.

Follow the steps to complete the form accurately.

1. Press the 'Get Form' button to access and open the Request For Respiratory/Influenza Testing form.
2. Begin by filling out the submitter information. This includes entering the submitter fax number, phone number, authorization code, submitter's name, street address, city, state, and ZIP code. Ensure that you provide accurate contact details as this information is essential for communication.
3. Next, fill in the physician information, which includes the physician's name, street address, city, phone number, and fax number. Completing this section is vital as it identifies the ordering physician for the test.
4. Then, provide the patient information. Enter the patient's first and last name, birthdate, and age. Include the patient's Medicaid identification number if applicable, and indicate if the patient is pregnant. Additionally, record the patient's identification number, race, sex, and ethnicity.
5. In the test information section, enter the date the specimen was collected and the onset date of the illness. This is a required field. Indicate the appropriate specimen source type by checking the relevant box and also assess if the patient meets the approved testing criteria.
6. Finally, review all the information entered and confirm that everything is accurate. Once you are satisfied, save the changes you made. You can then download, print, or share the completed form as needed.

Complete and submit the Request For Respiratory/Influenza Testing form online today!