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Please Select Insurance Type and add Primary Insurance Provider for Testing Options

Testing Option

DIAGNOSIS CODE(S); The ICD-10 codes provided are based on AMA guidelines and are for information purposes only. ICD-10 coding is the sole responsibility of the ordering provider

URINARY

N30.90: Cystitis, unspecified without hematuria
N30.91: Cystitis, unspecified with hematuria
N15.9: Renal tubule-interstitial disease, unspecified
N34.1: Nonspecific urethritis
N34.2: Other urethritis
N39.3: Stress incontinence

DIAGNOSIS CODE(S) |TYPE-IN

Icd10 gem codes

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Description *

Icd 10 gem codes	Icd 10 gem code description	Action

Patient Informed Consent

Introduction: This form describes the benefits, risks, and limitations of this test. Read this form carefully before making your decision about testing.

Purpose: The purpose of this test is to determine if you have a urinary tract infection with one of the agents that we test for, and to help your doctor select the best treatment.

How this Test Works: This test detects organisms in your urine and whether or not they display genes for antibiotic resistance.

Test Results: Your test results will be sent to the healthcare provider that ordered the test. Speak with him/her if you would like a copy of the test results. Your healthcare provider is responsible for interpreting the test results and explaining the meaning to you.

Financial Responsibility Statement: I hereby authorize Lab Stat, and its designees to furnish my designated insurance carrier, health plan or third party administrator
(i) all information I, or someone on my behalf, including my healthcare provider, provides to you in connection with the testing, and
(ii) the test results, as necessary for reimbursement. I also authorize all applicable benefits of my plan to be payable to Lab Stat or its designees for the services provided.
I understand that I am responsible for any amounts not paid by insurance for reasons including, but not limited to, non-covered or non- authorized services, to the extent permitted by applicable law and/or applicable network provider contracts with insurers.

PHYSICIAN SIGNATURE:

Signature on File or on Order
N/A Due to Public Health Emergency (COVID-19)

Use Physician Signature

I authorize Lab Services LLC and its affiliated labs to perform testing as directed by this test order form. I understand and hereby acknowledge that: When ordering test for which Medicare or Medicaid reimbursement will be sought, physicians should only order tests that are medically necessary for the diagnosis or treatment of the patient. Read more

PATIENT SIGNATURE:

For non-touch screen devices, the patient needs to type their full name below, and provide a secondary identifier.

Add Signature

By selecting the Add Signature button, I attest that I approve of this digital signature

Signature on File or on Order
N/A Due to Public Health Emergency (COVID-19)

I voluntarily consent to the collection and testing of my specimen and certify that the specimen identified on this form is my own, and has not been adulterated in any manner. I certify that the information provided on this form and on the specimen, is accurate. Read more

PATIENT

PROVIDER

First Name:

First Name

Middle Name:

Middle Name

Last Name:

Last Name

DOB:

DOB

Gender:

Gender

Country:

Country

Address:

Address

Address 2:

Address2

City:

City

State:

State

Zip Code:

Zip Code

Email:

Passport ID:

Phone No:

Phone No

Additional Phone No:

Additional Phone No

Patient Ethnicity:

Patient Ethnicity

Race:

Race

Weight (lbs.):

Weight (lbs.)

Height :

Height

Clinical information

Reference ID:

Reference ID

Social Security Number:

Social Security Number

Insurance Type :

Insurance Type

Bill to:

Bill to

Illness/Accident Date

Illness/Accident Date:

Accident Type :

Accident Type

Accident State:

Physician Name:

NPI:

Performing Lab:

Insurance Detail

CARES ACT Questions

COLLECTION DETAILS

DIAGNOSTIC CODES

Collected Date:

Date of Collection

Time Of Collection:

Time Of Collection

Collector Name:

Collector Name

Specimen Type:

Report Notes

MEDICATIONS

Allergies

Clinical Information

Known Drug Allergies

Genetic Test Order

Physician Signature / Date

Patient Signature / Date

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PHYSICIAN SIGNATURE:

PATIENT SIGNATURE: