Downloadable Forms

Submitter:

______________

Patient

(Information required - please print)

Name:

____________________________

Account #:

______________

Parent's Name:

____________________________

Physician:

______________

Address:

____________________

____________________

Address:

____________________

____________________

Phone #:

____/____/___________________

DOB:

____/____/____Sex:____________

Phone #:

____/____/__________

Soc Sec:

_______/_______/_____________

Fax #:

____/____/__________

Patient Status:

Single_____ Married_____ Other_____
Employed_____ Student_____

Patient Relationship:

Self_____ Spouse_____ Child_____

Specimen Information

Test Requested
Lyme Antibody Analysis	_____
Babesia microti (serology)	_____
Ehrlichia (HGE) (serology)	_____
Ehrlichia (HME) (serology)	_____
Lyme PCR (synovial fluid)	_____
Babesia PCR	_____
Ehrlichia (HGE) PCR	_____

Date of Collection

Type (serum/CSF)

_____/_____/_____

______________

_____/_____/_____

______________

Medicare/Private Insurance

Medicare #:

______________________

Medicare:

Primary___Secondary___

Ins Co Name:

______________________

Claim Address:

______________________

______________________

Policy Holder Name:

______________________

Clinical Information (Optional)
_____________________________________

_____________________________________

_____________________________________

Certificate #:

______________________

Group #:

______________________

Member #:

______________________

Prior Auth.#:

______________________

Plan Referral #:

______________________