COVID-19 Registrtion Form

Site ID:

Site Location:

Site Address:

COVID-19 by PCR Requisition Form
*No other test may be ordered on this COVID-19 by PCR requisition form*

WRITE LEGIBILY!

Ordering Physician: Dr. Erica Schwartz, MD Ordering Physician NPI: 1427034826 Quest Account Number: 73916469 LabCorp Account Number: 32044780 Result to: Maximus					CPT Code: 87635 Test Name: COVID-19 by PCR Sample Type (circle one): Anterior Nares, Foam ICD-10 Code: Z03.818
1. DATE of Collection (MM/DD/YYYY)					2. TIME of Collection
/ /2020
3. LAST NAME			4. FIRST NAME					5. DATE of BIRTH (MM/DD/YYYY)
								/ /
6. SEX	7. LANGUAGE			8. RACE					9. ETHNICITY
Male Female	(if not English)			Asian Black White Unknown Other			American Indian/ Alaska Native Native Hawaiian/ Other Pacific Islander Not Specified		Hispanic/Latino Non-Hispanic/Latino Not Specified
10. ADDRESS						11. CITY
12. STATE		13. ZIP CODE				14. PHONE NUMBER (primary)
						Cell / Home
15. INSURANCE CARRIER NAME						16. GROUP NUMBER
17. MEMBER/INDIVIDUAL NUMBER

Patient has verbally provided informed consent to participate in this testing: YES NO

Patient has received a copy of the privacy notice: YES NO

Barcode [should match the Barcode on the specimen tube]