Facility Name / Telephone / Ordering Physician
Street / Fax #1
City / State / Zip / Fax #2 / UPIN / NPI #
PATIENT INFORMATION [PLEASE PRINT] / Patient Diagnosis: / ICD-9 Code:
Patient: First Name / Last Name / Responsible Party (if other than patient)
Date of Birth / MM/dd/yyyy / Male Female / Relationship to Patient
Street Address / Street Address
City / State / Zip / City / State / Zip
Telephone / Telephone
Bill to: / Client / Up front payment (check / credit card) / Patient / Medicare / CO Medicaid
**IF BILLING MEDICARE, or CO MEDICAID, PLEASE INCLUDE PHOTO COPY OF FRONT & BACK OF CARD or provide information below**
CARRIER NAME / BILLING ADDRESS
Address
City
State ZIP / ID NUMBER / GROUP NUMBER
PHONE NUMBER / SUBSCRIBER / SUBSCRIBER DOB
I request payment of medical benefits for the laboratory services directly to ADx Labs NJH. I authorize ADx Labs NJH to release to any medical carrier providing medical benefits to me and any health plan of which I am a member, any medical or other information needed for claim or payment purposes. I acknowledge I am responsible for any services not covered by my medical carrier.
Patient Signature: / Date:
Specimen Source: Serum Plasma Blood Urine Other: / Collect Date: / Collect Time:
Raw Specimen OR Culture Medium: / Submitter Specimen #:
Form completed by [Print name]: / Date / Telephone
REFERRAL LAB 1000 (09.30.10)
HYPERSENSITIVITY SCREENING ANTIGENS / ASPERGILLUS ANTIGENS / MISC MOLD ANTIGENSTH3 / Thermoactinomyces vulgaris / ASPF1 / Aspergillus fumigatus #1 / AFABID / Fungal Antibodies by ID
T1 / Micropolyspora faeni / ASPNG / Aspergillus niger / (Histoplasma, Blastomyces,
Coccidioides and Aspergillus)
CAND / Candida / ASPFL / Aspergillus flavus
EB1 / Pigeon serum / M1 / Aspergillus polyvalent mix
TH5 / Aureobasidium pullulans / ASPF6 / Aspergillus fumigatus #6
M1 / Aspergillus polyvalent mix
BIRDS ANTIGENS / MOLD ANTIGENS / MISCELLANEOUS
EB1 / Pigeon serum / M1 / Aspergillus polyvalent mix / PPTP / Antigens supplied by client
EB2 / Pigeon droppings / M2 / Alternaria sp / Specify:
EB4 / Canary droppings / M5 / Fusarium
EB6 / Parakeet droppings / M11 / Penicillium mix
EB8 / Parrot droppings / M17 / Verticillium
EB10 / Cockatiel droppings / THERMOPHILE ANTIGENS
EB12 / Cockatoo droppings / TH3 / Thermoactinomyces vulgaris
T1 / Micropolyspora faeni
MILK ANTIGENS / TH5 / Aureobasidium pullulans
WMILK / Whole milk / M1 / Aspergillus polyvalent mix
MILK5 / 1:5 dilution of whole milk / FARMERS LUNG ANTIGENS
MIL50 / 1:50 dilution of whole milk / GP4 / Grain dust
BSA10 / Bovine serum albumin 10mg / GP5 / Grain dust (western)
BGG10 / Bovine gamma globulin 10mg / GP6 / Hay
CAS10 / Casein 10mg / FL4 / Chicken serum
LAC10 / Lactalbumin 10mg / TH3 / Thermoactinomyces vulgaris
BOVS / Bovine serum / T1 / Micropolyspora faeni
BOVG / Bovine globulins / TH5 / Aureobasidium pullulans
M1 / Aspergillus polyvalent mix
COMMENTS:
**Please call lab for availability of other antigens not listed above**
REFERRAL LAB 1000 (09.30.10)