Non GYN Cytology Requisition

Patient Information

Physician Iinformation

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Collection Information

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

(See List Below)

Clinical Information

Specimen A Description
Specimen B Description
Number Air Dried
Number Air Dried
Number Fixed
Number Fixed
Number vial(s) / containers
Number vial(s) / containers

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.

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