Register Now - Afro-BioMeDx

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COVID-19 Molecular Test Requisition

Afro 1 11

INSURANCE INFORMATION

Insurance CarrierClaims Address
Policy Holder’s Relationship to Patient
SelfSpouseDependent
Secondary Insurance (if available)

Policy #/Insured ID #Claims Phone #Policy Holder’s DOB

Group #Policy Holder’s Name
Policy Holder’s Sex
FM
Group #

SPECIMEN INFORMATION

Swab: Nasopharyngeal SwabOropharyngeal SwabOther
Collection Media: Viral Transport Media, such as UTM® or UVT®Sterile Saline

TESTING

V2.0 SARS-CoV-2 RT-PCR Test: Initial TestFollow-up Test

REQUIREMENTS

Volume: 1 mL
Shipping and Storage:

Multiple swabs from the same patient can be combined in a single vial for testing
Store at 2–8° C and ship overnight on ice pack, or store frozen at -70° C and ship overnight
on dry ice
Do not leave specimen refrigerated more than 72 hours after collection
Do not use calcium alginate tips, swabs with preservatives, or cotton swabs with wood shafts
Label specimen container with patient first and last name and DOB
Each specimen transport vial should be submitted with its own separate requisition and
transported in its own sealed bag

Ordering clinician should enter the signs, symptoms and ICD-10 code(s) that best describes the reason(s) for performing the test.
Clinicians should order only tests that are medically necessary for the diagnosis or treatment of the patient. In keeping with the requirements of Medicaid and Medicare, it is the policy of Inform
Diagnostics only to perform testing that is medically necessary for the diagnosis and treatment of patient.

Clinician Signature (Required)

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