URMC / Pathology & Laboratory Medicine / Clinical Laboratory Services / For Healthcare Providers / Consent and Other Forms / One Time Authorization One Time Authorization * Indicates required field Submitting Provider* * Primary Contact Name* * Primary Contact Email Address* * Phone Number* ( ) - * Fax Number* ( ) - * Department/Office Name* * Street Address City State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Zip Patient Name* * Medical Record Number* (If not available, specify "N/A".) * Sex Male Female Date of Birth (in form MM/DD/YYYY)* * Health Insurance (List all, separated by commas) Diagnosis* * Compliance is Mandatory and Regulated. For the laboratory to bill property and receive payment for tests ordered on Medicare Beneficiaries, specific ICD-9 code(s) or a descriptive diagnosis must be included on each patient for each test ordered. It is critical that the diagnosis provided to lab is consistent with those recorded in the patient medical record on the date of service. Tests Requested (List all, separated by commas)* * Explanation* * Please provide patient diagnosis and a detailed explanation as to how results of requested test(s) will influence your clinical management and care of this patient. If the patient is a hospital in-patient, please explain how these results will influence your treatment plan during current admission. I am the Physician of record or a Consulting Physician caring for the patient identified above. I am requesting a laboratory assay that may not be provided by the URMC Laboratories of Strong Memorial Hospital/Highland Hospital and may require shipment of sample to an outside reference laboratory to perform this assay. I understand that the time required to process, ship, and to receive results from an outside reference laboratory generally requires a minimum of five (5) business days, and that for certain assays, results may not be available for several weeks. In making this request I certify that the results of the laboratory assay(s) that I have requested above are medically necessitated and are likely to alter my diagnosis and/or my treatment plan for this patient. I Accept: * Yes Submit Our Privacy Policy
