Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the Clinical Requisition Form and open it for editing.
2. In the sample information section, enter the date of sample collection in MM/DD/YY format, the time of collection, and the temperature recorded. Additionally, state who collected the sample.
3. Proceed to patient information. Fill in the last name, first name, middle initial, gender, date of birth, and phone number of the patient.
4. In the billing information section, select the appropriate option: Insurance, Self Pay, or Client Bill. If using insurance, attach a copy of both sides of the current insurance card. Specify who is insured and fill in the policy number, group number, insurance carrier, and contact information.
5. Describe the diagnosis, signs, or symptoms in ICD-10 format in the provided space. Ensure that this information is complete and accurate.
6. In the individual components section, check all relevant disease panels and tests that apply to the patient. Ensure that you double-check the codes for accuracy.
7. Fill in the physician authorization section with the practitioner’s name and NPI number, ensuring that the information provided is correct.
8. After filling out the necessary sections, obtain the required signatures for both the physician authorization and patient consent/authorization. Ensure all legal responsibilities are acknowledged in the consent.
9. Once all the information is completed and verified, users can save changes, download, print, or share the form as needed.

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