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

Traveler ID
Patient Information
Month: Day: Year:






Physician Information
Specimen Information
Billing Information




ICD 10 Codes
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ICD 10 codes ICD 10 code description Action
Active Medication List
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Please Select Insurance Type and add Primary Insurance Provider for Testing Options

Testing Option

PHYSICIAN SIGNATURE:

Use Physician Signature
When ordering the tests, The physician is required to make independent medical decisions with regards to each test ordered. Only tests that are medically necessary will be reimbursed by the government or the private health plan. Read more

PATIENT/LEGAL REPRESENTATIVE SIGNATURE:

For non-touch screen devices, the patient/legal representative 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

I, the patient or legal representative, authorize Advanced Diagnostic Laboratory to perform testing and to release my test result to my health care provider and/or facility. I authorize Advanced Diagnostic Laboratory to obtain Read more
PATIENT
PROVIDER
Insurance Detail
COLLECTION DETAILS
DIAGNOSTIC CODES
Medical Necessity
Infectious Disease Test Order
 
Physician Signature Not Available

Physician Signature / Date

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Patient Signature / Date