CHECK APPROPRIATE BOX FOR BILLING
INSURANCE BILLING: COMPLETE SECTION 1-6 BELOW
GRANT ACCOUNT
PATIENT BILLING (SELF PAY): COMPLETE SECTION 1-2 BELOW
WHOLESALE/ACCOUNT
MICROBIOLOGY LABORATORY REQUEST FORM
PATIENT NAME (LAST, FIRST, MI) - PLEASE PRINT
PATIENT HISTORY #
LAST
DOB
FIRST
MIDDLE
PHYSICIAN NAME
(LAST, FIRST)
SEX
M
F
PHONE/PIC #
PHYSICIAN
SIGNATURE
PATIENT LOCATION
DATE & TIME OF COLLECTION
1. PATIENT ADDRESS (STREET OR PO BOX)
CITY/STATE
2. PATIENT PHONE #
ZIP CODE
PATIENT SOCIAL SECURITY #
PATIENT MARITAL STATUS
S
GUARANTOR NAME (LEAVE BLANK IF PATIENT IS GUARANTOR)
GUARANTOR PHONE #
GUARANTOR ADDRESS (STREET OR PO BOX)
CITY/STATE
3. MEDICARE: PRIMARY/SECONDARY
MEDICARE # & LETTER
5. OTHER INSURER
PRIMARY
EFFECTIVE DATE
M
W
RACE
D
W
B
OTHER
RELATIONSHIP TO PATIENT
ZIP CODE
4. MEDICAID #
STATE
COMPANY NAME
ADDRESS
SUBSCRIBER NAME
POLICY #
EFFECTIVE DATE
PHONE #
SECONDARY
GROUP #
Specimen Source (must specify specimen source)
First Systems & Resources, Inc (434) 973-4152
Fax ( 434) 973-6892
Aspirate
Biopsy/Tissue
Blood
Bone Marrow
Bone
Bronchial Brush
Bronchial Wash
Bronchoalveolar Lavage
Cervical/Vaginal
CSF
Dialysate
Eye
Gastric
Hair
Mucocutaneous
Nasopharynx-(NP)
Nail
Nasal Washing
Rectal
Scalp
Sinus
Skin
Sputum
Stool
Synovial
Throat
Transbronchial Biopsy
Urethral
Urine
Urine - Indwelling Cath
Urine - in - out Cath
Urine - suprapubic
Vaginal/rectal
Vitreous
Wound, Deep
Wound, Superficial
Other (describe)
special site
CULTURES
ICD9 CODE
TEST NAME
CULTURES
TEST CODE
ICD9 CODE
TEST NAME
Bacteriology
Aerobic Bacteriology
Special Request
Aerobic & Anaerobic Bacteriology
Special Request
Gram Stain
Blood Culture
C. Difficile Assay
Culture for Grp B Strep
Culture, Grp A Beta Strep Only
Mycobacteriology
(BACUL)
(ANACUL)
(GRSTN)
(BLC)
(CDIFTX)
(CBS)
(CTS)
(Culture confirmation for negative rapid screen in office)
Grp A Beta Strep Scrn (throat only)
(TS)
(Rapid screen + culture confirmation if negative)
Legionella DFA
Neisseria Gonorrhoea Culture
Pneumocystis DFA
Stool Culture
Fecal Leukocytes
Fecal Lactoferrin
Urine Culture
(LEGDIF)
(GCS)
(PCPSTN)
(STC)
(FL)
(FLAC)
(UC)
Mycology
33211
11/04
CSF Fungal Culture
Cryptococcal Antigen (check source)
Blood
Spinal Fluid
Fungal Culture
Fungal Screen (Dermatophytes)
TEST CODE
(FUNCSF)
(CRYPGB)
(CRYPG)
(FUNCUL)
(FUNSC)
(BLCAFB)
(AFBCSF)
(AFBCUL)
(AFBU)
AFB Blood Culture
AFB CSF Culture
AFB Culture
AFB Urine Culture
Parasitology
Cryptosporidium
Giardia Screen
Ova & Parasites
Special Request
Virology
Blood
Suspected Agent
Cytomegalovirus
Herpes Simplex
Influenza A and B
(Available only Nov-Mar)
Influenza culture only - screen negative
Respiratory
(all viruses from respiratory sources)
Suspected Agent
Resp. Syncytial Virus Screen
Rotavirus Screen
Varicella Zoster Virus DFA
Viral (non-respiratory sources only)
Suspected Agent
(CMSPOR)
(GSS)
(QOP)
(VCB)
(VSCMV)
(VSHSV)
(VSFLU)
(VSINF)
(VCRESP)
(RSVSCR)
(VSROTA)
(VZVDFA)
(VCUL)
Additional testing (smears, stains, susceptibilities, and organism identifications) will be performed for appropriate specimen types, unless otherwise indicated by
ordering physician.