One Time Authorization for Restricted or Off-Formulary Tests

* Indicates required field
If there is no Medical Record Number, specify "N/A".
Sex*
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.

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.



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