KPC Biotech Molecular Laboratory

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

VAGINITIS

TEST REQUISITION FORM

Patient Information
Billing Information
Billing 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: Vaginal Swab

Collector Initial:  

ORDERING CLINICIAN / LABORATORY INFORMATION
ICD-10 CODES

SPECIMEN TYPES: Vaginal Swab
COMMON SIGNS & SYMPTOMS: Consider if patient presents with vaginal discharge, odor, itching, and/or discomfort, bacterial
vaginosis, or vulvovaginal candidiasis. N76.0, N76.1, N76.89, N77.1, N93.9, R30.0, Z72.51

Facility/Practice Name:

Office Contact Name:

Office Phone Number:

Ordering Physician:

NPI #:

ICD-10 Codes: 

 Bacteria
 Atopobium vaginae
 Bacteroides fragilis
 BVAB-2
 Chlamydia trachomatis
 Enterococcus spp
 Escherichia coli
 Gardnerella vaginalis
 Haemophilus ducreyi
 HSV-1 (Herpes Simplex)
 HSV-2 (Herpes Simplex)
 Lactobacillus crispatus
 Lactobacillus gasseri
 Lactobacillus iners
 Lactobacillus jensenii
 Megasphaera Type 1
 Megasphaera Type 2
 Mobiluncus curtisii
 Mobiluncus mulieris
 Mycoplasma genitalium
 Mycoplasma hominis
 Neisseria gonorrhoeae
 Prevotella bivia
 Staphylococcus aureus
 Streptococcus agalactiae (GBS)
 Treponema pallidum
 Trichomonas vaginalis
 Ureaplasma urealyticum


Fungi
Candida albicans
Candida dubliniensis
Candida glabrata
Candida krusei
Candida lusitaniae
Candida parapsilosis
Candida tropicalis

KCDx-102324

Vaginitis

Physician Signature:

X

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