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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