KPC Biotech Molecular Laboratory

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

URINARY TRACT INFECTION

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:  Urine (Clean Catch)

Collector Initial:  

ORDERING CLINICIAN / LABORATORY INFORMATION
ICD-10 CODES

SPECIMEN TYPES: Urine (clean catch)
COMMON SIGNS & SYMPTOMS: Consider if patient presents with dysuria, hematuria, urgency of urination, frequency of micturition, or pain of micturition. N30.00, N30.01, N39.0, N39.1, R30.0, R30.9, R31.0, R35.0, R82.9, R82.998, Z87.440

Facility/Practice Name:

Office Contact Name:

Office Phone Number:

Ordering Physician:

NPI #:

ICD-10 Codes: 

Bacteria
Acinetobacter baumannii
Bacteroides fragilis
Citrobacter freundii
Citrobacter koseri
Enterobacter cloacae
Enterococcus spp
Escherichia coli
Klebsiella aerogenes
Klebsiella oxytoca
Klebsiella pneumoniae
Morganella morganii
Mycoplasma genitalium
Mycoplasma hominis
Prevotella bivia
Proteus mirabilis
Pseudomonas aeruginosa
Serratia marcescens
Staphylococcus aureus
Staphylococcus epidermidis
Staphylococcus saprophyticus
Streptococcus agalactiae (Group B Strep)
Streptococcus pyogenes (Group A Strep)
Ureaplasma urealyticum


Fungi
Candida albicans
Candida dubliniensis
Candida glabrata
Candida krusei
Candida parapsilosis
Candida tropicalis
Antibiotic Resistance Genes
blaKPC
blaNDM
CTX-M-Group 1
dfrA
mecA
qnr
Sul
vanA
 vanB

KCDx-102324

Urinary Tract Infection (Clean Catch)

Physician Signature:

X

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