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Get Center for Genetics Clinical Urine Drug Screen Test Requisition

010 Tulsa, OK 74136 Phone 918-502-2290 Fax 918-502-2292 O O INSURANCE ( PROVIDE CARD) SELF PAY LAST NAME _______________________________ FIRST NAME ___________________________ MI ___ DOB (MM/DD/YY) ____________ SSN OR OTHER ID __________________________ ICD-9-CM DIAGNOSIS CODE REQUIRED: _____________________________________ Requesting Physician: ____________________________ Ordering Physician Signature:_______________________________ Print Name ï‚¡ CLINICAL URINE DRUG SCREEN WITH REFLEX TO .

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Keywords relevant to Center for Genetics Clinical Urine Drug Screen Test Requisition

  • ICD-9-CM
  • b
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