www.wisconsinlab.com

Phone: (262) 574-0701

Fax:    (262) 574-0703

Wisconsin Viral Research Group

 Test Request Form


W229 N1870 Westwood Drive
Waukesha, Wisconsin 53186

Enclose completed form with sample.                                                                       Rev 09-2013

I.  Patient Information

Name (last, first):                                                                 Date of Birth:                          M/F

Address:                                                                                        Phone:

 

II. Ordering Physician Information: Please include a FAX number for result reporting

Name:                                                                                                   UPIN#:

Address:

 

FAX Results To:                                            Phone:                           Contact Person:

III. Payment Information: Please note: Our laboratory does not bill patients, patient's insurance or Medicare**

Payment by: (choose one)        Check           Money Order     Credit Card (fill out information below)

Name on Credit Card:

Credit Card Information: (circle one)          VISA      Master Card      Discover      American Express

Credit Card Number:                                                                                     Exp Date:

All self-paying patients will receive a standard HCFA insurance submission form for insurance purposes.

**Medicare Advance Beneficiary Notice

These tests are not covered by Medicare unless you are an organ transplant recipient or a patient with HIV Disease.  I understand that Medicare will not pay for my testing.

 

 _________________________________________________    Patient Signature

IV. Specimen Information: (circle one)   Blood  CSF  Bone Marrow       Other

Date Collected ((Required)                                                                                         Phleb:

V. ICD-9 Code(s): Required (systemic complaint and/or diagnosis) 1)            2)             3)             4)

VI. Tests:                  

                    _____  Nested HHV-6 DNA PCR (#1100)     _____  Nested HCMV DNA PCR (#1400)

                    _____  Nested EBV DNA PCR (#1200)        _____  HHV-7 DNA PCR (#1300)

Shipping Instructions: FedEx is our preferred shipper. Ship Monday through Thursday using the "PRIORITY OVERNIGHT - NEXT BUSINESS MORNING" shipping option. 

Ship to:

 

Wisconsin Viral Research Group, Inc.
W229 N1870 Westwood Drive
Waukesha, Wisconsin 53186

 

 

     

For Lab Use Only  Received:                                         Accn #                                         Mailer