Willis-Knighton Community Reference Laboratory 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Patient Information section. Enter the patient's name, Social Security Number (SS#), date of birth (DOB), and sex in the designated fields.
3. Next, answer the Medicare Secondary Payor (MSP) questions by circling 'Yes' or 'No' for each query regarding employment status, treatment conditions, and authorization from the Department of Veterans Affairs.
4. In the Bill To section, provide details about billing preferences by selecting CLIENT, PATIENT, or INSURANCE and entering relevant information such as insurance company name and contact details.
5. Complete the Physician Information section with the physician's name, address, phone number, and any necessary home health agency details.
6. Select any approved AMA panels or individual tests required for the patient by checking the appropriate boxes.
7. Finally, ensure all sections are filled accurately before signing at the bottom. Save your changes and download or share your completed form directly from our platform.

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