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Get IA Mercy Outpatient Lab Order Form

 /  Ordering Provider  Consult Dr.  Patient Location  When Tests are Complete:  Patient SSN  □ Send Patient Home  □ Send Patient to Office  □ Page Provider on Pager#  □ Call Results to  □ Fax Results to  □ Courtesy Copy to  Patient Phone Number  Narrative Signs/Symptoms/Diagnosis  1.  2.  3.  4.  Notification to Providers and other persons legally authorized to order tests for which Medicare reimbursement will.

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