ACCOUNT


Laboratory Requisition


BILLING INFORMATION MUST BE COMPLETED

PROFILES

PANELS

KEY: S - SERUM B - BLUE L - LAVENDER R - RED Y - YELLOW U - URINE G - GRAY R - PLAIN RED T - TIGER TOP

MEDICARE ADVANCE BENIFICIARY NOTICE (ABN)

I authorize the release of medical information necessary to process this claim and request payment of benefits to the party who accepts assignment. I permit the copy of this authorization to be used in place of the original. I understand that medicare is likely to deny payment for certain procedures. I agree to be personally responsible for payment of laboratory services if Medicare does not provide payment.