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Get Neuromuscular Disease Center Muscle/Nerve/Skin Biopsy Request Form 2003-2024
52044 : Medicare Provider # 26-8235 Internet Home Page http://www.neuro.wustl.edu/neuromuscular Referring institution Patient name Requesting physician Sex Send report to Date biopsy received NAME ADDRESS CITY, STATE, ZIP PHONE & FAX # Age DOB WU Lab accession # Bill charges to Labs other than Washington University: If we are billing patient, please provide insurance authorization number. Clinical Diagnosis & History Specimens & Site biopsied Surgeon INSTRUCTIONS Hand carried fresh.
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