Documents Upload – Rapid Mobile Lab

Company Name:

Ordering Date:(Required)

Address:

Physician:

Phone:

NPI:

Type of Business:

Fax Number:

PATIENT INFORMATION

Name:(Required)

Date of Birth:(Required)

Sex:(Required)

Address:

Phone:(Required)

Facility Name:(Required)

Room #(Required)

Social Security :(Required)

BILLING INFORMATION

Medicare #

Medicaid #

Insurance Provider

Policy Number:

Group Number:

Self-Pay

Diagnosis Codes

Lab Test Names

Fasting?

Additional Test or Insutrctions

Ordering Priority

It is necessary for the physician to authorize:

1. That the patient meets the status of “Homebound” as defined below
2. The insurer accepts billing for this “homebound” phlebotomy service. If there is any question regarding insurances, please contact the laboratory billing department conducting the tests. THE DEFINITION OF “HOMEBOUND” STATUS IS 204.1 – An individual does not have to be bedridden to be considered as confined to home. However, the conditions of the patients should be such that there exists a normal inability to leave the home, and consequently, leaving their home requires a considerable and taxing effort. It is expected in most instances absences from the home that occur will be for the purpose of receiving medical treatment. “FCFA: HHA Manuel-Pub. 11, Revision 227

Yes, the patient is hombound due to the following:

This field is hidden when viewing the form

Section Break

Lab Contact Person

Phone:

Fax:

Critical Value Notification Person:

Phone:

ARNP Name:

Phone:

Email:

Preferred Results Delivery Method

Website Portal

Fax

Name of Physician or Authorized Rep. For Physician Uploading Document:(Required)

Date

Rapid Mobile Lab

PATIENT INFORMATION

BILLING INFORMATION

Section Break

Rapid Mobile Lab

Areas we serve

Resources

Weekly Newsletter

Physicians