Gastroenterology Requisition A-F

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Gastroenterology Requisition A-F

Patient Information

Patient Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Phone Number

Sex *

SS Number

Physician Information

Requesting Physician Signature *

Billing Information (please attach copies of all cards, front and back)

Primary *

Billing Information Attached
Medicare
Medicaid
Other Insurance
Self Pay
Bill Ordering Physician

Insuance Carrier:

Policy / ID Number

Group Number

Secondary *

Medicare
Medicaid
Other Insurance
Self Pay
Bill Ordering Physician

ICD-10 Codes(s)

(See List Below)

Clinical Information (Copy of endoscopic findings may be attached)

Clinical Info *

Abdominal Pain
Chest Pain
Constipation
Abnormal X-Ray
Cirrhosis
Diarrhea
Anemia / Iron Def
Cancer Screening
Dyspepsia
Barrett's
Celiac Disease
Dysphagia
BRBPR
Change in bowel habits
GERD

Clinical Info

GI Bleeding
Hx PUD
Hematemesis
Mass
Heme + Stool
Melena
Hx IBD
Nausea / Vomiting
Hx Polyps
Nsaid Usage
Varices

Personal Hx of -

Breast / Gyn Cancer
Colon Cancer
Other

Family Hx of -

Breast / Gyn Cancer
Colon Cancer
Other

Endoscopic Findings

Comments

R/O Barrett's
R/O Eosinophilic Esophagitis
R/O Malignancy
R/O Celiac Disease
R/O H. Pylori
R/O Microscopic Colitis
R/O Dysplasia
R/O Inflammatory Bowl Disease
R/O Polyp
Other

Specimen Submitted

Biopsy Site(s) A

Biopsy Site(s) B

Biopsy Site(s) C

Biopsy Site(s) D

Biopsy Site(s) E

Biopsy Site(s) F

Patient Consent: I authorize payment to be paid to A2Z Diagnostics, LLC shown above for laboratory testing benefits otherwise payable to me. I understand I am financially responsible to A2Z Diagnostics, LLC for charges not paid or payable under my insurance program attached. I understand that my insurance may not be able to honor this request. If they cannot, they will pay the benefits directly to me as the insured and will direct payment to A2Z Diagnostics, LLC.

Patient Signature *

A (Name and Site)

B (Name and Site)

C (Name and Site)

D (Name and Site)

E (Name and Site)

F (Name and Site)

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