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*** CLIENT BILL ONLY NO PATIENT OR THIRD PARTY BILLING ON THIS ACCOUNT ***
PAYMENT INFORMATION

Payment method:  CLIENT BILL ONLY/ACCOUNT BILL ONLY

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This requisition is not available for insurance billing.

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This requsition form has been paid for.

ORDER INFORMATION

Requisition #:

Order Date:

VOID AFTER

26046

23-01-2024

23-01-2025

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Bill Quest Account Number:

PHYSICIAN/PATIENT INFORMATION

Ordering Physician:

Physician NPI No: 

Full Name: 

Email: 

Phone Number: 

The physician has electronically signed this form.

Patient Information:

First Name:

DANTE

Last Name:

COOPER

Sex:

Male

DOB:

01-01-1970

Phone:

441-292-5111

Address:

38 King Street

City:

Hamilton

State:

ZIP:

HM 12

ORDER INFORMATION
TSH: 899,