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
6950
24-08-2021
24-08-2022
PHYSICIAN/PATIENT INFORMATION
Ordering Physician:
Physician NPI No:
Full Name:
Email:
Phone Number:
The physician has electronically signed this form.
Patient Information:
First Name:
Danny
Last Name:
Test
Sex:
Male
DOB:
12/12/1999
Phone:
4444444444
Address:
City:
State:
ZIP:
ORDER INFORMATION
Stool Culture: 8144 - Stool,