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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the patient's name in the designated fields for 'Last' and 'First'. Ensure accuracy as this is crucial for identification.
- Fill in the referring facility's Medical Record Number (MRN) along with the patient's phone number and address, including city, state, and zip code.
- Select the patient's sex and enter their date of birth. This information is essential for processing.
- Attach a copy of the insurance card or face sheet as required under 'Insurance Info'.
- Complete the requesting facility section by providing the facility name, physician's name, NPI number, and contact details.
- In the testing & sample information section, select the appropriate tests being requested and provide sample collection dates and times.
- Finally, ensure that all required signatures are obtained before submitting your form through our platform.
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