5034131234 2026

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4 out of 5

53 votes

The document is a Prenatal Screening Requisition form from Legacy Laboratory Services, detailing the necessary information required for prenatal screening tests. It includes sections for patient and provider details, collection dates, diagnostic codes, and specific requirements for first and second trimester screenings. The form emphasizes the importance of using contracted labs with insurance and includes confidentiality notices regarding the transmission of medical information.

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Click ‘Get Form’ to open the Prenatal Screening Requisition in the editor.
Begin by filling in the clinic name, provider name, address, and phone number at the top of the form. Ensure all details are accurate for proper processing.
Enter the patient's legal name (last, first, middle initial) and date of birth in the required fields. This information is crucial for identification.
Provide the last four digits of the patient’s social security number and select their sex by checking either 'Male' or 'Female'.
Fill in the collection date and patient’s home address. Both fields are marked as required.
Complete the diagnosis code section and ensure you provide all necessary information regarding maternal ethnicity, weight, estimated delivery date, and other relevant medical history.
Finally, sign and date where indicated to authorize the requisition before submitting it through our platform.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (208 Votes)
2016	4 Satisfied (53 Votes)

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