KPC Biotech Molecular Laboratory

1117 E Devonshire Ave, Hemet, CA 92543
CLIA#: 05D2227042
Fax: (951) 765-4829
Tel: (800) 249-9478

RESPIRATORY PLUS

TEST REQUISITION FORM

Patient Information
Billing Information
Billing Information
Specimen Information

Patient Name:

Date of Birth: ___ / ___ / ______ (MM/DD/YYYY)

Gender:  Male __   Female __

Social Security #:

Address:

City:  ______________________________  State:  ______  Zip:

Phone #:

(please include a copy of the front & back of the insurance card)

 


BILL:
Medicare ___   Medi-Cal ___  Insurance ___

Policy Name Holder (if not patient)

___________________________

Patient relationship to policy holder 

Self: ___ Spouse: ___ Child: ___ Other: _______

Policy holder Date of Birth:  ___ / ___ / ______ (MM/DD/YYYY)

Social Security #

Insurance Company Name:

Billing Address:

City, State, Zip:

Insurance ID:

Employer/Company Name:

Group #:

Authorization (Patient Signature):

X

ABN: I request and authorize KPC Biotech Molecular Laboratory to perform the designated test(s) on the DNA sample provided by me.  My signature above constitutes my acknowledgement that I have been informed of the benefits and limitations of this testing which have been explained to my satisfaction by a qualified health professional.  I also understand that reference/testing lab reserves the right to provide de-identified information of a statistical nature to accrediting agencies and reserves the right to use such anonymous information.
Assignment of Benefits: I hereby authorize the entity to bill my insurance company and receive payment from them on my behalf.  I acknowledge, however, that I am responsible for payment of my account and any and all charges associated with it’s collection.  I hereby authorize the entity, or their designee, to appeal my health plan on my behalf to provide the actions and information necessary to overturn the denial or receive reimbursement for the underpaid claim.  This authorization shall remain valid until the charges for the orders on this form are paid in full.

 

Collection Date: ____ / ____ / ______  Time:

Source: Nasopharyngeal/Nares Swab

Collector Initial:  

ORDERING CLINICIAN / LABORATORY INFORMATION
ICD-10 CODES

SPECIMEN TYPES: Nasopharyngeal/Nares Swab
COMMON SIGNS & SYMPTOMS: Consider if patient presents with symptoms of an upper respiratory tract infection, including cough,
moderate temperature elevation, and mucopurulent sputum. J00, J02.9, J06.0, J06.9, J10.1, J18.9, J20.8, J22, R05.1, R05.2, R06.02,
R06.2, R07.1, R50.9

Facility/Practice Name:

Office Contact Name:

Office Phone Number:

Ordering Physician:

NPI #:

ICD-10 Codes: 

 Bacteria
 Acinetobacter baumannii
 Enterobacter cloacae
 Haemophilus influenzae
 Klebsiella aerogenes
 Klebsiella pneumoniae
 Moraxella catarrhalis
 Proteus mirabilis
 Pseudomonas aeruginosa
 Staphylococcus aureus
 Staphylococcus epidermidis
 Streptococcus pneumoniae
Streptococcus pyogenes
      (Group A Strep)
 
 Atypical Bacteria
 Bordetella pertussis
 Chlamydia pneumoniae
 Legionella pneumophila
 Mycoplasma pneumoniae
 
Antibiotic Resistance Genes
mecA
 Viruses
 Adenovirus
 Bocavirus
 COVID-19 Coronavirus (SARS-CoV-2)
 Enterovirus
 Epstein-Barr Virus (mononucleosis)
 Human metapneumovirus (A)
 Human metapneumovirus (B)
 Influenza A
 Influenza B
 Other Coronaviruses (229E)
 Other Coronaviruses (HKU1)
 Other Coronaviruses (NL63)
 Other Coronaviruses (OC43)
 Parainfluenza virus (type 1)
 Parainfluenza virus (type 2)
 Parainfluenza virus (type 3)
 Parainfluenza virus (type 4)
 Respiratory Syncytial Virus (Types A & B)
Rhinovirus (types A & B)

KCDx-102324

Respiratory Plus

Physician Signature:

X

My Signature, as attending physician, serves as authorization of this test as medically necessary.