[Name of Practice]
-104775-2571740Home Draw Request FormFax 727-733-3973 (8am – 4pm Monday – Friday) Phone: 727-733-5036Today’s Date: FORMTEXT ?????BC Client # FORMTEXT ?????Office Requesting : FORMTEXT ?????** FAX AT LEAST THREE DAYS IN ADVANCE TO ALLOW FOR SCHEDULING **Person Requesting & Phone: FORMTEXT ?????Ordering Physician: FORMTEXT ?????PATIENT INFORMATIONAddressCity /Zip : Last: FORMTEXT ?????Middle: FORMTEXT ?Doctors Phone : ( FORMTEXT ?????) FORMTEXT ?????First: FORMTEXT ?????Birth date: FORMTEXT ?????Doctors Fax Number : ( FORMTEXT ?????) FORMTEXT ?????Social Security Number:Home phone no.:Other Phone:Sex:Results to Physician? FORMTEXT ?????( FORMTEXT ?????) FORMTEXT ?????( FORMTEXT ?????) FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMCHECKBOX Call FORMCHECKBOX FaxPatient Street address:City:State:ZIP Code: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Single FORMCHECKBOX Mar FORMCHECKBOX Div FORMCHECKBOX Wid FORMCHECKBOX FORMCHECKBOX Patient on AnticoagulantCopy Results To:Special Instructions: FORMTEXT ????? FORMTEXT ?????DIAGNOSIS CODE(S): FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????INSURANCE INFORMATIONSubscriber’s name:Insurance NameAddress:Phone no.: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????( FORMTEXT ?????) FORMTEXT ?????Please indicate primary insurance FORMCHECKBOX MACROBUTTON DoFieldClick [Insurance] FORMCHECKBOX Medicare FORMCHECKBOX Medicaid FORMCHECKBOX Self Pay FORMCHECKBOX OtherGroup no.:Policy no.:Other Insurance : FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Document claim address/submit front/back copy of insurance cardIf Medicare patient and diagnosis code does not support medical necessity, patient will be required to fill out an ABN form indicating that the patient has accepted responsibility for payment if charges are denied by MedicareTEST INFORMATION FORMCHECKBOX Routine FORMCHECKBOX STAT FORMCHECKBOX Timed Collection FORMCHECKBOX Standing OrderStart Date: FORMTEXT ?????REQUESTED DRAW DATE: FORMTEXT ?????Frequency: FORMTEXT ?????End: FORMTEXT ????? FORMCHECKBOX CBC w/diff FORMCHECKBOX CBC w/PLT No Diff FORMCHECKBOX H & H FORMCHECKBOX Chol Fract / Lipid Panel FORMCHECKBOX Digoxin FORMCHECKBOX Bun/Creat FORMCHECKBOX Basic Metabolic Panel (NA, K, CL, CO2, BUN, Creat,CA) FORMCHECKBOX Comp Metabolic Panel (NA,K CL CO2 BUN, Creat, CA, TP, Alb, AST, Alk Phos, T Bili ALT) FORMCHECKBOX TSH 3rd Generation FORMCHECKBOX Absolute Neutrophil FORMCHECKBOX PT / INR FORMCHECKBOX Other (separate tests with Comma) FORMTEXT ?????Other Continued : FORMTEXT ?????Additional Information: FORMTEXT ?????*Note: Tests ordered within panels may also be ordered IndividuallyFor Lab Use Only: Soarian Entered by:______________ Date: _______ Time: _________ Comments: _______________________Definition of “homebound” status** Must be completed by ordering medical professional **Synonymous with confined to the home, as for medical reasons. “204.1 – An individual does not have to be bedridden to be considered as confined to home. However, the conditions of these patients should be such that there exists a normal inability to leave the home, and consequently, leaving their home requires a considerable and taxing effort… It is expected in most instances, absences from the home that occur will be for the purpose of receiving medical treatment.” CMS: HHA Manual – Pub. 11, Revision 227 I hereby confirm that this patient meets CMS Homebound criteria by the presence of my signature below. FORMTEXT ????? FORMTEXT ?????Ordering Medical Providers Signature (REQUIRED)Date ................
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