General Requisition

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INS. ID & GROUP POLICY OR CREDIT CARD #

Diagnostic Profiles/Panels

Additional Tests/Profiles

Vitamin

130 - VITAMIN B-12 (SST)

131 - VITAMIN D, 25-HYDROXY (SST)

Hematology

020 - CBC/PLATELET COUNT / DIFF (LAV)

56/157 - PROTHROMBIN TIME (PT/INR) (BLU)

158 - PTT (BLU)

212 - SEDIMENTATION RATE (ESR) (LAV)

Microbiology

OCCULT BLOOD (CARD)

746 - THROAT CULTURE (SWAB)

590 - URINE CULTURE W/ SENSITIVITY (SC)

019 - URINALYSIS, COMPLETE (SC)

Tumor Markers

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I authorize release of any medical or other information necessary to process my claim and authorize payment of my medical benefits to Avantic Medical Lab.
MEDICARE ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN).

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By checking this box and typing my name, I am electronically signing my application.

ADDITIONAL TESTS/PROFILES

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Patient Information

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Diagnostic Profiles/Panels

Additional Tests/Profiles

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