Fill - Free fillable COVID- Requisition- Fillable-041520 Respiratory Requisition Dr Office Urgent Care.xlsx PDF form

DateSpecimenCollected TimeSpecimenCollected

Group/PracticeName

OrderingPhysicians AddressLine1

☐ ☐☐ AddressLine2

☐ ☐☐ City,StateZip

☐ ☐☐ Phone Fax

☐☐☐ Other

FirstName LastName MI DOB Gender

AddressLine1 AddressLine2 City State Zip

HomePhone CellPhone Race* Ethnicity*

Insured'sName RelationshiptoPatient SocialSecurity#

HomePhone CellPhone DOB Gender

PrimaryInsurance SecondaryInsurance

Group# ID# Group# ID#

Address Address

City State Zip City State Zip

OropharyngealSwabORNasopharyngealSwab:

☐ RespiratoryPathogenPanelwithCOVID‐19(SARS‐CoV‐2Assay)

☐

COVID‐19(SARS‐CoV‐2Assay)

☐ J12.89Otherviralpneumonia ☐ A37.90Whoopingcough

☐ J20.8Acutebronchitisduetootherspecifiedorganisms ☐ A48.1Legionnaires'disease

☐ J22Unspecifiedacutelowerrespiratoryinfection ☐ B95.0GroupAStreptococcus

☐ J80Acuterespiratorydistresssyndrome ☐ J02.0Streptococcalpharyngitis

☐ R05Cough ☐ J02.9Pharyngitis,unspecified

☐ R06.02Shortnessofbreath ☐ J06.9Acuteupperrespiratoryinfection,unspecified

☐ R50.9Feverunspecified ☐ J11.1FluLikeSymptoms

☐ Z20.828Contactwithandsuspectedexposuretootherviral ☐ Other___________________________________

communicabledisease ☐ Other___________________________________

RapidInfluenzaTest☐Yes☐No☐Positive☐Negative

Rapid

StrepTest☐Yes☐No☐Positive☐Negative

SignatureofPhysicianorOtherAuthorizedNPIProvider(REQUIRED) AccessionerInitials

_________________________________________________________________________________1__________ 2_________

*Race

andEthnicityarerequiredbycertainstatesandtheCDC **Seereversesidefordetails

Pleaseindicatewhetherarapidinfluenzatestorarapidstreptestwasperformedintheofficetoday

COVID‐19CODESARELISTEDBELOWANDMUSTBECHECKEDOFF

RespiratoryRequisition

LaboratoryUseOnly

PracticeContactInformation

AccessionNumber

PatientandInsuranceInformation

(CurrentlyNotAcceptingMedicaidorManagedMedicaidPlans‐ContractPending)

ICD‐10Codes

TestPanels

DateReceived TimeReceived

ThroatSwab:

☐ GroupAStreptococcus

UpperRespiratoryPanel

ICD‐10Codesarelistedforinformationpurposesonly.Itistheprovider'sresponsibilitytoorderteststhataremedicallynecessaryandinthebestinterestofthepatient.

1912 Rt 35 S, Ste 203, Oakhurst, NJ 07755

P: 732-389-1530 IF: 732-389-0352 I Courier P: 732-508-9154

.labofchoice.com

GLM Expanded Respiratory Panel

Bacteria

Bordetella (parapertussis, bronchiseptica)

Bordetella pertussis

Chlamydophila pneumoniae

Haemophilus Influenzae

Klebsiella pneumoniae

Legionella pneumoniae

Mycoplasma pneumoniae

Streptococcus pneumoniae

Staphylococcus aureus

Viruses

Adenovirus

Bocavirus

Coronavirus 229E

Coronavirus HKU1

Coronavirus NL63

Coronavirus OC43

Enterovirus

HHV3 (Varicella Zoster Virus)

HHV4 (Epstein Barr Virus)

HHV5 (Cytomegalovirus)

Influenza A H1-2009

Influenza A H3

Influenza A pan

Influenza B

Parainfluenza Virus 1

Parainfluenza Virus 2

Parainfluenza Virus 3

Parainfluenza Virus 4

Respiratory Syncytial Virus (RSV) A

Respiratory Syncytial Virus (RSV) B

Rhinovirus

Fungal Target

Pneumocystis jiroveci

Focused Viral Panel

Influenza A

Influenza B

Respiratory

Syncytial Virus (RSV)

Group A Streptococcus

Streptococcus pyogenes

SARS-CoV-2 / COVID 19

PLEASE NOTE: The Thermo Fisher TaqMan 2019-

nCoV Assay Kit v1 and TaqMan 2019-nCoV Control

Kit v1 Test and/or TaqPath COVID-19 Combo Kit is

indicated as an aid in the diagnosis of specific

agents of respiratory illness and results are meant

to be used in conjunction with other clinical,

laboratory, and epidemiological data. Positive

results do not rule out co-infection with organisms

not included in the Thermo Fisher TaqMan 2019-

nCoV Assay Kit v1 and TaqMan 2019-nCoV Control

Kit v1 and/or TaqPath COVID-19 Combo Kit. The

agent detected may not be the definite cause of

this disease.

A Positive result indicates the presence of SARS-

CoV-2 RNA but does not exclude bacterial infection

and/ or coinfection with other viruses. The agent

detected may not be the definitive cause of

disease. This result should be combined with

clinical observation, patient history, and

epidemiological information for patient

management decisions.

Negative results do not preclude SARS-CoV-2

infection and should not be used as the sole basis

for treatment and other patient management

decisions. Negative results must be used in

conjunction with clinical observation, patient

history, and epidemiological information for

patient management decisions.

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