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780 Cedar Lane

Teaneck, NJ 07666

Ph : 208-907-6668

Email : info@dntplab.com

Web : www.dntplab.com

COVID-19 PCR Test Requisition Form

PATIENT'S INFORMATION
Upload File
GENDER
Do You Have Insurance ( if no, Please provide copy of your valid ID: )
Upload File
PLEASE ANSWER THE FOLLOWING QUESTION:
SPECIMEN COLLECTION
DIAGNOSES ( ICD 10-CODES )

I certify that the information provided on this form is accurate. I authorize dNTP Laboratory ("the lab") to release the results of this test to the ordering provider. I further authorize the lab to bill my insurance and to receive payment of benefits for the test ordered. I authorize the lab to release to my insurance provider any medical information necessary to process this claim. If the insurance is inactive on the date of service, I agree to pay the bill provided by the lab.

ACKNOWLEDGEMENT

Thanks for the order. We'll get back to you soon.

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