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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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