Note: All information with a red asterisk ( * ) must be completed

Patient Information
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Is Opt-in Text Messages

Physician Information
Physician Order not Required
Reference ID
Laboratory Information
Specimen information
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Clinical information


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
ICD-10 Code


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.


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


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

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
Insurance Detail
CARES ACT Questions
Report Notes
Clinical Information
Infectious Disease Test Order
Physician Signature Not Available

Physician Signature / Date


Patient Signature / Date