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
6872
23-07-2021
23-07-2022
PHYSICIAN/PATIENT INFORMATION
Ordering Physician:
Physician NPI No:
Full Name:
Email:
Phone Number:
The physician has electronically signed this form.
Patient Information:
First Name:
Billy
Last Name:
Sams
Sex:
Male
DOB:
2000-08-22
Phone:
3333333333
Address:
City:
State:
ZIP:
ORDER INFORMATION
SMN1 Copy Number Analysis: G00517,