Transcription of General Request Form - Mayo Medical Laboratories
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General Request Form - Mayo Medical Laboratories
Page 1 of 2T239 MC1360rev1118 General RequestClient Information (required)Client NameClient Account PhoneClient Order CodePatient Information (required)Patient ID ( Medical Record No.)Patient Name (Last, First, Middle)Gender Male FemaleBirth Date (Month DD, YYYY)Collection Date (Month DD, YYYY)Time s Street AddressPhoneCityStateZip CodeMML Internal Use OnlyShip specimens to: mayo Medical Laboratories 3050 Superior Drive NW Rochester, MN 55901 Customer Service: 855-516-8404 Billing Information An itemized invoice will be sent each month. Payment terms are net 30 the Business Office with billing related questions: 800-447-6424 (US and Canada) 507-266-5490 (outside the US) 2018 mayo Foundation for Medical Education and ResearchInsurance Information (required)Subscriber s Name (if different than patient)Patient Relationship Spouse Dependent Other _____Medicare HIC Number (if applicable) Medicaid Number (if applicable)Insurance Company s Name (if applicable)Insurance Company s Street AddressCityStateZip CodePolicy NumberGroup Number I hereby confirm that informed consent has been signed by an individual legally authorized to do so and is on
Page 1 of 2 T239 MC1360rev0318 General Request Form Client Information (required) Client Name Client Account No. Client Phone Client Order …
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