Urinary Tract Infection Panel (UTI)

Urinary Tract Infection Panel (UTI)

Requisition Form

Internal Use Only

Collection Date/Time Patient Last Name

/

/

Patient Street Address

Patient Phone #

Office Contact

:

AM PM

Patient First Name

Receiving Date/Time

City

Gender

Male

Office Email/Phone

Female

/

/

Date of Birth

State

Height

Physician NPI#

:

AM PM

Zip Code Width

Gram Positive Organisms:

Staphylococcus spp. (CNS) Streptococcus agalactiae Staphylococcus aureus Streptococcus pneumoniae Enterococcus faecalis Enterococcus faecium

URINARY TRACT INFECTION PANEL (UTI)

Urinary Tract Infection Panel With AB Sensitivity

Gram Negative Organisms:

Tested Resistance Genes:

Acinetobacter baumannii Citrobacter freundii Enterobacter aerogenes Enterobacter cloacae Escherichia coli Klebsiella oxytoca

Klebsiella pneumoniae Morganella morganii Proteus mirabilis Providencia stuartii Pseudomonas aeruginosa Serratia marcescens

Methicillin (mecA) Carbapenems (KPC) Vancomycin (VAN B) Vancomycin (VAN A1/2)

Fungi:

Candida albicans Candida glabrata Candida krusei Candida torpicalis Candida parapsilosis

BILLING INFORMATION

Bill to: Insurance HSA Medicaid Medicare Self Pay Worker's Compensation Please include photocopy of both sides of insurance card and face sheet

Name of Person Insured

Relationship to Insured

DOB of Insured

UTI DIAGNOSIS ICD-10 CODES

Additional ICD-10 codes:

N30.00 Acute cysitis without hematuria N30.01 Acute cystitis with hematuria N30.90 Cystitis, unspecified without hematuria R06.89 Other breathing abnormalities R06.1 Stridor N39.0 Urinary tract infection, site not specified N40.1 Benign prostatic hyperplasia with lower

urinary tract symptoms

R10.9 Unspecified abdominal pain R30.0 Dysuria R31.0 Gross hematuria R31.29 Other microscopic hematuria R31.9 Hematuria, unspecified R32 Unspecified urinary incontinence R33.9 Retention of urine, unspecified R35.0 Frequency of micturition

R35.1 Nocturia R39.15 Urgency of urination R53.83 Other fatigue R80.9 Proteinuria, unspecified R82.90 Unspecified abnormal findings in urine Z79.899 Other long term (current) drug therapy R39.9 Unspecified symptoms and signs

involving the genitourinary system

I request and authorize CoreBioLabs to perform the designated test(s) on the sample provided by me. My signature below constitutes my acknowledgment that I have been informed of the benefits and limitations of this testing which have been explained to my satisfaction by a qualified health professional. Assignment of Benefits: I hereby authorize CoreBioLabs or its affiliate to bill my insurance company and receive payment from them on my behalf. I acknowledge, however, that I am responsible for payment of my account and any and all charges associated with its collection. I hereby authorize my insurance company to pay the company directly for services rendered. Appeal Authorization: In the event of an underpayment or denial by my insurance carrier, I hereby authorize the company or their designee, to appeal my health plan on my behalf to provide the actions and information necessary to overturn the denial or receive reimbursement for the underpaid claim. This authorization shall remain valid until the charges for the orders on this form are paid in full. Donor Signature: I certify that I provided my specimen to the collector; that I have not adulterated it in any manner; each specimen used was sealed in my presence; and that the information provided on this form and on the label affixed to each specimen is correct. I authorize the release of the results to the ordering clinician, authorized client/representative, or prescribing/attending physician. I authorize CoreBioLabs or its affiliates to release any information required for billing purposes. I acknowledge CoreBioLabs or its affiliates may be an out of network provider with my insurer. I also agree that in a case where my insurance provider sends payment directly to me, I will endorse the insurance check and forward to CoreBioLabs within 30 days.

Print Patient Name

Patient Signature

Date

Physician Certification: I hereby request and authorize reference/testing lab to utilize this information to perform UTI testing for the indicated patient. I certify that I have explained UTI testing to the patient indicated in this requisition form. I also certify that I will only use and disclose test results as permitted by law.

Physician Authorizing Name

Physician Authorizing Signature

Date

CoreBioLabs ? 8285 Darrow Rd. #101, Twinsburg, OH 44087 ? Phone: (330) 405-2623 ? Fax: (330) 405-0859 Web: ? E-mail: info@ ? CLIA# 36D2061372 ? CAP# 7541618

Revision 1.1, August 2019

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2 1

3

?

Remove stopper and keep for later use!

Attach plastic straw.

?

Insert the plastic straw into

the container and fill the Urine Monovette? up to the bottom of the label.

43

?

4

To empty the plastic tube,

hold the Urine Monovette?

?

in an upright position and

pull the plunger backwards

to the bottom of the tube.

?

Remove the plastic straw break off the plunger and throw away. Replace the stopper.

Waste

Technical modifications reserved

Paent Clean Catch Urine Collecon Instrucons

A. Wash hands thoroughly. Retrieve sample cup and check for unbroken "STERILE" seal. If this seal has been broken, please discard and use a sterile sealed specimen cup.

B. Open the sterile cup being sure not to touch the inside of the cup. C. Tear open the "Casle Soap Wipe" and remove towelee. D. Use as many as needed to clean the penis or vaginal area following the

appropriate instrucon below. i. Male: If uncircumcised, retract the foreskin and wipe from p to sha.

ii. Female: Spread labia (folds of skin) apart with one hand and wipe with a towelee. Wipe from front to back. Repeat this process two addional mes, each me using a fresh towelee (ulizing a total of 3 towelees).

E. Begin urinang into the toilet. While urinang, place the specimen container in posion to collect midstream in the sterile specimen cup. Use cauon to not touch the inside of the cup thus contaminang the specimen.

F. Aer at least 7mL of urine is in the container, put lid back on cup. Ensure proper sealing by listening for two clicks as you twist.

G. Place all soiled items into the wastebasket and wash hands thoroughly. H. Give container to the nurse for transfer into a sterile monovee for transport.

Review the test requision and sign if all informaon is correct.

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