COVID-19 (SARS-CoV-2) Requisition form
Please submit each specimen with its own requisition
and its own separate specimen bag.
ALL FIELDS MANDATORY
FOR LAB USE ONLY

1- PATIENT INFORMATION
Male Female

2-PATIENT RACE PATIENT ETHNICITY
American Indian or Alaskan Asian Not Hispanic/Latino
African American Native Hawaiian/Pacific Islander Hispanic or Latino
White Other race or Unknown Unknown

3- INSURANCE INFORMATION
UPLOADED DOCUMENTS [0] (IMAGE FILES ONLY)

4- PATIENT SCREENING FOR SYMPTOMS (within the past 14 days, do you have any of the following?)
-Fever Yes No
-Cough Yes No
-Shortness of breath Yes No
-Muscle Ache/Headache Yes No
-Diarrhea Yes No
-Loss of taste or smell Yes No
-Have you traveled using public transportation Yes No
-Where you outside of the United States Yes No
-Have you been exposed to Covid-19 or possible exposure Yes No
-Have you been ever tested positive for Covid-19 Yes No

ORDERING PHYSICIAN / PROVIDER SECTION
Test Requested
X SARS-COV-2 (COVID-19) Qualitative PCR
Specimen Source: Nasopharyngeal swab Nasal swab

ICD10/Diagnosis Code
Z11.59 -Encounter for screening for other viral diseases
Z03.818 -Encounter for Suspected exposure to other biological agents ruled out
Z20.828 -Contact with and suspected exposure to other viral and communicable disease
U07.1 -Covid 19(Confirmed cases) Signature of requesting physician:
On File
Other  

CPT Code
G2024 Sample Collection code
SPECIMEN COLLECTION
Facility Name

  Outpatient Hospital NH
UNINSURED PATIENT
You have verified and attest to the best of your knowledge the patient
does not have coverage through an individual, or employer-sponsored-
plan, federal Employee Health Benefits Program, federal health program,
Medicine, or Medicaid and no other payer will reimburse for
COVID-19 testing at the time the test was ordered:

Agree Disagree

ORDERING PHYSICIAN: ORDERING PHYSICIAN'S SIGNATURE:




CMS MEDICAL NECESSITY INFORMATION
It is or policy to provide health care providers with the ability to order only those lab tests medically necessary for the individual patient and to ensure that the convenience of ordering standard panels and custom profiles does not impact this ability. While we recognize the value of this convenience, indiscriminate use of panels and profiles can lead to ordering tests that are not medically necessary.

Total List

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