UTI & Wound Requisition - A2Z Diagnostics

Patient Information

Patient Name *

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Last

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Physician Information

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Collection Information

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

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Insuance Carrier:

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Secondary

ICD-10 Code(s)

Specimen Submitted

Wound Site

UTI

UTI Panel

Bacteria
• Acinetobacter baumannii • Chlamydia trachomatis • Citrobacter lreundii • Enterobacter aerogenes • Enterobacter cloacae • Enterococcus faecalis • Enterococcus faecium • Escherichia coli • Klebsiella pneumonia • Morganella morganii • Neisseria gonomoeae • Proteus mirabilis • Pseudomonas aeruginosa • Staphylococcus aureus • Staphylococcus saprophyticus • Streptococcus agolactiae • Streptococcus pyogenes • Trichomonas vaginalis

Fungus
• Candida albicans • Candida glabrata

Antibiotic Resistance
• AmpC b-lactamase, Class C • Carbapenemase, Class A • Carbapenemase, Class B • Carbapenemase, Class D • Ext.Spectrum-b-lactamase • Methicillin-resistant • Staphylcoccus aureus (MRSA) • Vancomycin-resistant Enterococcus (VRE)

Wound Panel

Wound Panel

Bacteria
• Acinetobacter baumannii • Citrobacter lreundii • Enterobacter aerogenes • Enterobacter cloacae • Enterococcus faecalis • Enterococcus faecium • Escherichia coli • Klebsiella oxytoca • Klebsiella pneumoniae • Morganella morganii • Mycobacterium avium • Mycobacterium intracellulare • Proteus species • Pseudomonas aeruginosa • Staphylococcus aureus • Staphylococcus epidermidis • Streptococcus agalactiae • Streptococcus pyogenes

Fungus
• Aspergillus flavus • Aspergillus fumigatus • Candida albicans • Candida glabrata

Antibiotic Resistance
• Carbapenemase, Class A • Carbapenemase, Class B • Carbapenemase, Class D • Ext.Spectrum-b-lactamase • Methicillin-resistant Staphylcoccus aureus (MRSA) • Panton-Valentine leukocidin (PVL) Positive MRSA • Vancomycin-resistant Enterococcus (VRE)

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 the payment to A2Z Diagnostics, LLC.

Patient Signature