Urinary Tract Receiving Date: Infection Panel (UTI ...

Urinary Tract Infection Panel (UTI)

INTERNAL USE ONLY Receiving Date: Receiving Time:

Physician Name Office Contact

ACCOUNT INFORMATION

Physician NPI#

Office Email

Office Phone

Collection Date

/

/

PATIENT DEMOGRAPHICS

Collection Time

:

AM PM

Patient Last Name

Patient First Name

Date of Birth

/

/

Patient Street Address

City

State

Zip Code

Patient Phone

Gender

Male Female

Height

Weight

URINARY TRACT INFECTION PANEL (UTI)

UTI PCR Panel Gram Positive Organisms:

UTI PCR Panel with Urinalysis Gram Negative Organisms:

* Positive PCR will reflex to an Antibiotic Susceptibility Test (AST)

Resistance Genes:

Fungi:

Staphylococcus saprophyticus Streptococcus agalactiae Staphylococcus aureus Streptococcus pneumoniae Enterococcus faecalis Enterococcus faecium

Acinetobacter baumannii Klebsiella pneumoniae

Citrobacter freundii

Morganella morganii

Enterobacter aerogenes Proteus mirabilis

Enterobacter cloacae Providencia stuartii

Escherichia coli

Pseudomonas aeruginosa

Klebsiella oxytoca

Serratia marcescens

Ampicillin Methicillin Carbapenem ESBL Macrolide Tetracycline

Quinolone Vancomycin

Candida albicans Candida glabrata Candida krusei Candida tropicalis 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 cystitis without hematuria N14.0 Analgesic nephropathy R82.71 Bacteriuria N20.0 Calculus of kidney N20.2 Calculus of kidney with calculus of ureter N71.1 Chronic inflammatory disease of uterus N11.9 Chronic tubule-interstitial nephritis, unspecified N30.90 Cystitis, unspecified without hematuria N42.9 Disorder of prostate, unspecified R30.0 Dysuria N18.6 End stage renal disease N73.9 Female pelvic inflammatory disease, unspecified

R50.9 Fever, unspecified N14.1 Nephropathy induced by other drugs,

medicaments and biological substances

N14.2 Nephropathy induced by unspecified drug,

medicament or biological substance

N34.1 Nonspecific urethritis R82.99 Other abnormal findings in urine R82.79 Other abnormal findings on microbiological

examination of urine

N28.89 Other specified disorders of kidney and ureter N76.89 Other specified inflammation of vagina and vulva A41.9 Sepsis, unspecified organism

N14.4 Toxic nephropathy, not elsewhere classified R82.90 Unspecified abnormal findings of urine N05.2 Unspecified nephritic syndrome with diffuse

membranous glomerulonephritis

N05.1 Unspecified nephritic syndrome with focal and

segmental glomerular lesions

NO5.0 Unspecified nephritic syndrome with minor

glomerular abnormality

N05.9 Unspecified nephritic syndrome with unspecified

morphologic changes

N34.3 Urethral syndrome, unspecified N20.9 Urinary calculus, unspecified N39.0 Urinary tract infection, site not specified

PATIENT REQUEST

I authorize any holder of medical or other information about me to release to the Social Security Administration, its intermediates, Blue Shield, or other carriers any information needed for this or related claims. I permit a copy of this authorization to be used in place of the original; and request payment of medical insurance benefits.

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 4.0, 5/6/2020

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