Blessing Hands
Mobile Services
Lab Order Form
PH: (484) 313-6777
FAX: (484) 771-9852
info@blessinghandsmobile.com
Patient Information
Full Name:
Date of Birth:
Phone Number:
Insurance Carrier:
Address:
Insurance ID#:
Ordering Provider Information
Provider Name:
Practice Name:
NPI:
Fax:
Phone:
Specimen Collection
Collection Date:
Collection Time:
Priority:
Yes
No
STAT
Fasting:
Yes
No
Priory:
ICD-10 Code(s):
Test(s) Ordered
| Test Name | Test Code | ICD-10 Code |
|---|---|---|
| Complete Blood Count | 85025 | |
| Comprehensive Metabolic Panel (CMP) | 80053 | |
| Basic Metabolic Panel | 80048 | |
| Lipid Panel | 80061 | |
| Hemoglobin A1c | 83036 | |
| Thyroid Panel | 84433/84439/84479 | |
| PT/INR | 85610 | |
| D-Dimer | 85379 | |
| C-Reactive Protein (CRP) | 86140 | |
| Urinalysis | 81001 | |
| Vitamin D (25-Hydroxy) | 82306 | |
| Vitamin B12 | 82607 | |
| H. Pylori Antibody | 86677 | |
| Ammonia Level | 82140 | |
| Other: | ||
| Other: | ||
Billing Information
Insurance Claim
Self-Pay
Follow Standing Order
Repeat Test
ICD-10 Code(s):
Provider Initials / Notes
Verified Identity
Fasting Confirmed
Health Rec/AA/#:
Patient Consent
I authorize Blessing Hands Mobile Services to perform specimen collection and handle my samples as required.
Patient Signature:
Date:
NOTICE: Blessing Hands Mobile Services does not perform diagnostic testing. All specimens are processed by licensed laboratories.