3494 Progress Drive, Bensalem, PA Fields Highlighted in ...

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Advanced Molecular Test Request Form

SEX:

M

PATIENT NAME:

SPECIMEN TYPE:

F

LAST

URINE

Fields Highlighted in Blue are Required ACCESSION #

E-SWAB FIRST

NASAL SWAB M

DATE OF BIRTH: PATIENT PHONE #:

PATIENT S.S. #:

COLLECTION DATE:

COLLECTION TIME: AM

PM

CURRENT PRESCRIBED MEDICATION:

Provider Signature

PAYMENT TYPE: CASH

PAYMENT INFORMATION

CREDIT CARD

AMOUNT: VISA

MASTERCARD

DISCOVER

AMERICAN EXPRESS

CREDIT CARD #: EXPIRATION DATE:

SECURITY CODE:

BILLING ADDRESS (IF DIFFERENT FROM ABOVE):

PATIENT ADDRESS (STREET ADDRESS, APT):

1

4

CITY, STATE, ZIP:

2

5

BILL TO:

3

6

*MAGELLAN

*COMMERCIAL INS

CLIENT

*MEDICARE

*WORKER'S COMPENSATION

PATIENT

*MEDICAID

*AUTO INSURANCE

*PLEASE ATTACH COPY OF INSURANCE CARD/INFORMATION

INSURANCE NAME AND/OR ID:

OTHER

DIAGNOSIS CODES (ICD-10):

WOULD LIKE REPORT BY: FAX #: EMAIL:

(PLEASE PROVIDE EMAIL ADDRESS)

(CITY, STATE, ZIP): CREDIT CARD HOLDER SIGNATURE:

MAIL: ONLINE ACCESS TO WEB RESULT PORTAL EMR INTERFACE

ADVANCED MOLECULAR PANELS

RESP

RESPIRATORY PANEL (NASAL SWAB) Bacterial

VAGM

Bordetella (Pan) Bordetella pertussis Chlamydophila pneumoniae Haemophilus influenzae Klebsiella pneumoniae complex Legionella pneumophila Mycoplasma pneumoniae Staphylococcus aureus Streptococcus pneumoniae

Viral

Adenovirus Coronavirus 229E Coronavirus HKU1 Coronavirus NL63 Coronavirus OC43 Enterovirus (pan assay) Enterovirus D68 Herpesvirus 6 (HHV6) HHV4 (Epstein-Barr virus) HHV5 (cytomegalovirus) Influenza A (Pan) Influenza A/H1-2009

Influenza A/H3 Influenza B Metapneumovirus (hMPV) Parainfluenza virus 1 Parainfluenza virus 2 Parainfluenza virus 3 Parainfluenza virus 4 Respiratory Syncyal Virus A (RSV A) Respiratory Syncyal Virus B (RSV B) Rhinovirus SARS-CoV-2

WOMEN'S HEALTH/ STD PANEL (E-SWAB)

Bacterial

Atopobium vaginae Bacteroides fragilis

Viral

HSV1 HSV2

BVAB2 Chlamydia trachomas Enterococcus faecalis Escherichia coli Gardnerella vaginalis Haemophilus ducreyi Lactobacillus crispatus Lactobacillus gasseri Lactobacillus iners

Fungi

Candida albicans Candida dubliniensis Candida glabrata Candida krusei Candida lusitaniae Candida parapsilosis Candida tropicalis Trichomonas vaginalis

Lactobacillus jensenii Megasphera 1

Megasphera 2

Mobiluncus cursii

Mobiluncus mulieris

Mycoplasma genitalium Mycoplasma hominis

Neisseria gonorrhoeae

Prevotella bivia

Staphylococcus aureus Streptococcus agalacae (group B)

Treponema pallidum (Syphilis)

Ureaplasma urealycum

WNDP UTMP

WOUND PANEL (E-SWAB)

Bacterial

Acinetobacter baumannii Acnobaculum schaalii Aerococcus urinae Alloscardovia omnicolens Citrobacter freundii Citrobacter koseri Coagulase Negave Staph Corynebacterium riegelii

Enterobacter aerogenes Enterobacter cloacae Enterococcus faecalis Enterococcus faecium Escherichia coli Klebsiella oxytoca Klebsiella pneumoniae Morganella morganii

Mycoplasma hominis Streptococcus agalacae Pantoea agglomerans Ureaplasma urealycum

Proteus mirabilis

Viridans Group Strep

Proteus vulgaris

Providencia stuari

Pseudomonas aeruginosa

Serraa marcescens

Staphylococcus aureus

Antibiotic resistant markers

ampC

OXA-1, GES, PER-1, PER-2 dfrA5, dfrA1 BIL/LAT/CMY

DHA

PER-1, PER-2

Sul1, Sul2 SHV

IMP-1 group, IMP-16, IMP-7 TEM

nfsA

VEB

OXA-23, 72, 40, blaOXA-48 mecA

FOX

KPC

VIM

QnrA, QnrS, Qnr B

ACC

CTX-M group 1, 2, 9, 8/25 vanA1, vanA2, vanB

MOX/CMY

Yeast

Candida albicans Candida auris Candida glabrata Candida parapsilosis

UTI PANEL (URINE CUP)

Bacterial

Acinetobacter baumannii Acnobaculum schaalii Aerococcus urinae Alloscardovia omnicolens Citrobacter freundii Citrobacter koseri Coagulase Negave Staph Corynebacterium riegelii

Enterobacter aerogenes Enterobacter cloacae Enterococcus faecalis Enterococcus faecium Escherichia coli Klebsiella oxytoca Klebsiella pneumoniae Morganella morganii

Mycoplasma hominis Streptococcus agalacae Pantoea agglomerans Ureaplasma urealycum

Proteus mirabilis

Viridans Group Strep

Proteus vulgaris

Providencia stuari

Pseudomonas aeruginosa

Serraa marcescens

Staphylococcus aureus

Antibiotic resistant markers

ampC

OXA-1, GES, PER-1, PER-2 dfrA5, dfrA1 BIL/LAT/CMY

DHA

PER-1, PER-2

Sul1, Sul2 SHV

IMP-1 group, IMP-16, IMP-7 TEM

nfsA

VEB

OXA-23, 72, 40, blaOXA-48 mecA

FOX

KPC

VIM

QnrA, QnrS, Qnr B

ACC

CTX-M group 1, 2, 9, 8/25 vanA1, vanA2, vanB

MOX/CMY

Yeast

Candida albicans Candida auris Candida glabrata Candida parapsilosis

CAB

COVID PANELS

COVID/ FLU COMBO PANEL (NASAL SWAB)

SARS-CoV-2 Influenza A/B

COVID-19 INDIVIDUAL TESTS

CV01 CV02 CV03

SARS-COV-2 RNA by PCR SARS-COV-2 IgG (Serum) SARS-COV-2 IgM (Serum)

I authorize the release of any medical informaon necessary to process this request. I permit a copy of this authorizaon to be used in place of the original.

PATIENT SIGNATURE

DATE

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