Requisition Form
- 1 Basic Info
- 2 Sample Info
- 3 Insurance Info
- 4 Review & Submit
Click "Next" to review and submit the form.
Personal Information Summary
| Email: | First Name: | ||
| Last Name: | MI: | ||
| DOB: | Gender: | ||
| Race: | Bill To: | ||
| Phone Number: | Address: | ||
| City: | County: | ||
| State: | Zip Code: |
Primary Insurance Information
| Insurance Code: | Insurance Name: | ||
| Subscriber First Name: | Subscriber Last Name: | ||
| Subscriber Middle Intial: | Subscriber DOB: | ||
| Subscriber Gender: | Subscriber Relationship to Patient: | ||
| Insurance Policy Number: | Insurance Group Number: | ||
| Guarantor First Name: | Guarantor Last Name: | ||
| Guarantor Middle Intial: | Guarantor Relationship to Patient: | ||
| Guarantor Address: | Guarantor City: | ||
| Guarantor State: | Guarantor Zip: |
Secondary Insurance Information
| Insurance Code: | Insurance Name: | ||
| Subscriber First Name: | Subscriber Last Name: | ||
| Subscriber Middle Intial: | Subscriber DOB: | ||
| Subscriber Gender: | Subscriber Relationship to Patient: | ||
| Insurance Policy Number: | Insurance Group Number: |
Tertiary Insurance Information
| Insurance Code: | Insurance Name: | ||
| Subscriber First Name: | Subscriber Last Name: | ||
| Subscriber Middle Intial: | Subscriber DOB: | ||
| Subscriber Gender: | Subscriber Relationship to Patient: | ||
| Insurance Policy Number: | Insurance Group Number: |
UNSURE WHAT TEST YOU SHOULD CHOOSE?
SARS-CoV-2, RT-PCR test: is used to measure the presence of the viral RNA and diagnose a COVID-19 active infection when an individual in is infected with the virus and/or is experiencing symptoms of the COVID-19 disease
SARS-CoV-2 IgG/IgM Rapid Antibody test: is used to measure the presence of IgG and IgM antibodies to the SARS-CoV-2 virus. Antibodies will only be present after infection with the virus or after vaccination.
SARS-CoV-2 Total Neutralizing Antibody (NAb) test: is used to measure if an individual has developed neutralizing antibodies to the SARS-CoV-2 virus. This test can identify individuals with an adaptive immune response to SARS-CoV-2 indicating prior infection or post-vaccination.