RESPIRATORY & COVID-19 We are closed on Thanksgiving Day, Christmas Day and New Year Day. INFORMATION: Self PayClient BillInsuranceMedicare/Medicaid PATIENT INFORMATION: MaleFemale Worker's Comp: ORDERING PHYSICIAN: Physician’s Medical Necessity Notice: You should only order laboratory tests that are reasonable and medically necessary for the diagnosis and treatment of your patient. Upon request, you must be able to provide documentation to support the medical necessity of the laboratory tests marked on this test request form for Auspicious Laboratory to perform. DIAGNOSIS CODE: Advanced Beneficiary Notice (ABN): [For Medicare Patients Only] When laboratory tests are ordered for a Medicare patient that you believe will not be paid by Medicare, you must have the patient sign an Auspicious Laboratory ABN form signed and dated by the patient at the time of service. Otherwise, Auspicious Laboratory will charge the client for laboratory tests not covered by Medicare. SPECIMEN INFORMATION FastingNon Fasting I certify that I have voluntarily provided a specimen for analytical testing. The information provided on this form and on the label affixed to thespecimen is accurate. I authorize Auspicious Laboratory Inc. to release the results of this testing to the treating physician or facility. I herebyinsurance benefits to be paid directly to Auspicious Laboratory Inc. for services I received. I acknowledge that Auspicious Laboratory Inc. may be an out-of-net work provider with my insurer. I am also aware that in some circumstances my insurer will send the payment directly to me. I agree to endorse the check and forward in to Auspicious Laboratory Inc. within 30 days of receipt. Failure to do so may result in my account being forwarded to Collections and to a Credit Bureau. I understand that Auspicious Laboratory, Inc may use my specimen and testing results, for research, development, and potential purposes, so long as the information has been properly deidentified p-ursuant to law. PATIENT’S SIGNATURE : SELECT TEXT (PANEL) REQUESTED WITH THIS PATIENT SAMPLE RPP-Respiratory Pathogen Panel COVID-19 RT-PCR (SARS-CoV-2) COVID-19 IgG/IgM Antibody Test BACTERIA Bordetella pertussis Bordetella parapertussis Chamydophila pneumoniae Mycoplasma pneumoniae VIRUSES Adenovirus Coronavirus HKU1 Coronavirus NL63 Coronavirus 229E Coronavirus OC43 Human Metapneumovirus Human RhinovirusEnterovirus Influenza A Influenza A/H1 Influenza A/H3 Influenza A/H1-2009 Influenza B Parainfluenza Virus 1 Parainfluenza Virus 2 Parainfluenza Virus 3 Parainfluenza Virus 4 Respiratory Syncydal Virus DIAGNOSTIC CODES REQUIRED Please make sure fill out the diagnostic codes at the top of this form. The list below has been provided for your convenience. This is not an all-inclusive list and the ordering physician should precribe the diagnostic codes that best describe the reason for performing each test whether or not it appears in the list. RESPIRATORY & COVID-19 Acute pharyngitis, unspecified J02.9 Covid-19 confirmed U07.1 Acute bronchitis due to other specified organisms J20.8 Encounter for screening for other viral diseases Z11.59 Acute bronchitis, unspecified J20.9 Encounter for observation for suspected exposure to other biological agents ruled out Z03.818 Acute upper respiratory infection, unspecified J06.9 Encounter for antibody response examination Z01.84 Acute sinusitis, unspecified J01.90 Fever, unspecified R50.9 Acute respiratory distress syndrome J80 Other viral pneumonia J12.89 Acute respiratory failure with hypoxia J96.01 Pneumonia, unspecified organism J18.9 Bronchitis, nor specified as acute or chronic J40 Unspecified acute lower respiratory infection J22 Chronic sinusitis, unspecified J32.9 Other specified respiratory disorders J98.8 Cough R05 Shortness of breath R06.02 Contact with and(suspected) exposure to other viral communicable diseaes Z20.828 We are closed on Thanksgiving Day, Christmas Day and New Year Day.