Get Covid-19 Test Requisition Form

Filling out the COVID-19 Test Requisition Form online can streamline the process of getting necessary testing. This guide provides clear, step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to fill out the form correctly

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Once you have the form open, begin by filling out the patient information section. Enter the patient's last name, first name, middle initial, mailing address, city, state, zip code, telephone number, email address, gender, and date of birth.
3. Proceed to the billing information section. Indicate whether you have Medicare Medical (Part B) coverage, fill in your Medicare number if applicable, and attach a copy of your Medicare card as instructed.
4. Sign the form in the designated area to accept financial responsibility and confirm that you are aware of the testing fees. This signature is required for processing.
5. Next, fill out the referring physician information. This includes the physician's name, title, practice address, city, state, zip, telephone number, fax number, NPI, and email.
6. In the test menu section, select the tests by checking the corresponding boxes. Provide the test codes and descriptions as required, ensuring you understand the specimen requirements and prepay prices associated with each test.
7. Complete the specimen information section, detailing who collected the specimen, the type of specimen collected, and the date and time of collection.
8. If available, include the PUI (patient under investigation) for reporting reference and ensure proper storage conditions for specimens are indicated.
9. Before submitting the form, check for completeness to avoid delays; all required fields must be filled out.
10. Finally, save any changes, download, or print the completed form for your records. You may also share the form as necessary, according to the instructions provided.

Complete your COVID-19 TEST REQUISITION FORM online to ensure timely processing and accurate results.