Patient Last, First Name, M - National Jewish Health



FACILITY / CLIENT INFORMATION [PLEASE PRINT] | |

|Facility Name       |Telephone       |Ordering Physician |

| | |      |

|Street       |Fax #1       | |

|City       |State    |Zip       |Fax #2       |UPIN       |NPI #       |

| |

|PATIENT INFORMATION [PLEASE PRINT] |Patient Diagnosis:       |ICD-9 Code:       |

|Patient: First Name       |Last Name       |Responsible Party (if other than patient)       |

|Date of Birth       |MM/dd/yyyy | Male Female |Relationship to Patient       |

|Street Address       |Street Address       |

|City       |State    |Zip       |City       |State    |Zip       |

|Telephone       |Telephone       |

|Bill to: | Client | Up front payment (check / credit card) | Patient | Medicare | CO Medicaid |

|**IF BILLING MEDICARE, or CO MEDICAID, PLEASE INCLUDE PHOTO COPY OF FRONT & BACK OF CARD or provide information below** |

|CARRIER NAME |BILLING ADDRESS |ID NUMBER |GROUP NUMBER |

|      |Address      |      |      |

| |City       | | |

| |State       ZIP       | | |

|PHONE NUMBER | |SUBSCRIBER |SUBSCRIBER DOB |

|      | |      |      |

|I request payment of medical benefits for the laboratory services directly to ADx Labs NJH. I authorize ADx Labs NJH to release to any medical carrier providing medical |

|benefits to me and any health plan of which I am a member, any medical or other information needed for claim or payment purposes. I acknowledge I am responsible for any |

|services not covered by my medical carrier. |

|Patient Signature: |Date: |

| |

|Specimen Source: Serum Plasma Blood Urine Other:       |Collect Date:       |Collect Time:       |

| Raw Specimen OR Culture Medium: |Submitter Specimen #:       |

|Form completed by [Print name]:       |Date       |Telephone       |

|HYPERSENSITIVITY SCREENING ANTIGENS |ASPERGILLUS ANTIGENS |MISC MOLD ANTIGENS |

| TH3 |Thermoactinomyces vulgaris | ASPF1 |Aspergillus fumigatus #1 | AFABID |Fungal Antibodies by ID |

| T1 |Micropolyspora faeni | ASPNG |Aspergillus niger | |(Histoplasma, Blastomyces, |

| | | | | |Coccidioides and Aspergillus) |

| CAND |Candida | ASPFL |Aspergillus flavus | | |

| EB1 |Pigeon serum | M1 |Aspergillus polyvalent mix | | |

| TH5 |Aureobasidium pullulans | ASPF6 |Aspergillus fumigatus #6 | | |

| M1 |Aspergillus polyvalent mix | | | | |

|BIRDS ANTIGENS |MOLD ANTIGENS |MISCELLANEOUS |

| EB1 |Pigeon serum | M1 |Aspergillus polyvalent mix | PPTP |Antigens supplied by client |

| EB2 |Pigeon droppings | M2 |Alternaria sp |Specify:       |

| EB4 |Canary droppings | M5 |Fusarium | |

| EB6 |Parakeet droppings | M11 |Penicillium mix | |

| EB8 |Parrot droppings | M17 |Verticillium | |

| EB10 |Cockatiel droppings |THERMOPHILE ANTIGENS | | |

| EB12 |Cockatoo droppings | TH3 |Thermoactinomyces vulgaris | | |

| | | T1 |Micropolyspora faeni | | |

|MILK ANTIGENS | TH5 |Aureobasidium pullulans | | |

| WMILK |Whole milk | M1 |Aspergillus polyvalent mix | | |

| MILK5 |1:5 dilution of whole milk |FARMERS LUNG ANTIGENS | | |

| MIL50 |1:50 dilution of whole milk | GP4 |Grain dust | | |

| BSA10 |Bovine serum albumin 10mg | GP5 |Grain dust (western) | | |

| BGG10 |Bovine gamma globulin 10mg | GP6 |Hay | | |

| CAS10 |Casein 10mg | FL4 |Chicken serum | | |

| LAC10 |Lactalbumin 10mg | TH3 |Thermoactinomyces vulgaris | | |

| BOVS |Bovine serum | T1 |Micropolyspora faeni | | |

| BOVG |Bovine globulins | TH5 |Aureobasidium pullulans | | |

| | | M1 |Aspergillus polyvalent mix | | |

|COMMENTS:       |

|**Please call lab for availability of other antigens not listed above** |

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PRECIPITIN REQUISITION

1400 Jackson Street

Denver, Colorado 80206

Client Services 800.550.6227, option 6

clinreflabs@

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