THIS IS REQUISITION FOR LABCORP ONLY
DirectDx.net
1-888-283-4741
Draw Scheduling: ( optional )
Call 888-522-2677
*** CLIENT BILL ONLY NO PATIENT OR THIRD PARTY BILLING ON THIS ACCOUNT ***
PAYMENT INFORMATION
Payment method: CLIENT BILL ONLY/ACCOUNT BILL ONLY
Labcorp Account #:
* This requisition is not available for insurance billing.
ORDER INFORMATION
Requisition #:
Order Date:
VOID AFTER
13834
16-02-2022
16-02-2023
PHYSICIAN/PATIENT INFORMATION
Ordering Physician:
Physician NPI No:
Full Name:
Email:
Phone Number:
The physician has electronically signed this form.
Patient Information:
First Name:
test
Last Name:
patient 4
Sex:
Male
DOB:
04/12/2002
Phone:
321456789
Address:
City:
State:
ZIP:
ORDER INFORMATION
Test Lab Test Individual: 99999999,