TEST REQUISITION

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Laboratory / Account Information9410 Carroll Park Drive San Diego, CA 92121 TOLL FREE: (888) 423-5227 PHONE: (858) 824-0895 FAX: (877) Nestl Health Science CompanyTEST REQUISITIONPLEASE PRINTPatient Information (required) LAST NAME FIRST NAME MIADDRESS APT. STATE ZIPHOME PHONE # OTHER PHONE #DOB SEX M F SSNProvider / Account InformationACCOUNT NAME / ADDRESSPHONE FAXPROVIDER / NPI #ICD-9 CODES (required)CLINICAL DIAGNOSISDATE COLLECTED (required):TIME COLLECTED:PATIENT ID #SENDER SAMPLE ID #MEDICARE ONLY - HOSPITAL STATUS WHEN SAMPLE WAS COLLECTED Hospital Inpatient Hospital Outpatient Non-Hospital PatientLABORATORY NAME / ADDRESSPHONE FAXCONTACTRESULTS Mail Fax No results to labDX13030-NY 05/13BILL: Provider Account Insurance Laboratory Patient Medicare.

diagnosis, care, and treatment of this patient’s condition. Ordering Provider’s Signature Date Print Name PRIMARY INSURANCE: As a courtesy, we will bill your insurance. Please attach a copy (front and back) of insurance card(s) and complete all information below. NOTE: Parent or guardian information required if patient is a minor.

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