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PROVIDER DIAGNOSIS CHANGE REQUEST FORM
Today’s Date: Client Account#:_G
Client Account Name:
Referring Physician:
Client Contact Person:
Client Contact Phone#:
Patient Name:
Case Number: OR Patient DOB:
(ProPath Accession # or Patient Account #)
Please specify which test each diagnosis should be applied to. Each ICD-10 code must include the complete code set (e.g. Z12.4, R87.810, etc.)
New Diagnosis: Test: Pap
New Diagnosis: Test: HPV (If ordered as HPV Only or Regardless of Result)
New Diagnosis: Test: Chlamydia trachomatis
New Diagnosis: Test: Neisseria gonorrhoeae
New Diagnosis: Test: Trichomonas vaginalis
New Diagnosis: Test: Gardnerella vaginalis
New Diagnosis: Test: Candida
New Diagnosis: Test: Herpes simplex virus 1 and 2
New Diagnosis: Test: Group B Streptococcus
Physician Signature: ____________________________________________ Date: ________________
(Physician signature is required)
Please Fax back to (214) 631-6724
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