This form takes about five minutes to complete. You’ll need the following information and documents for this order:
- Patient profile or demographics
- Most recent clinical note
- Patient’s insurance information
- ICD-10 code of the diagnosis
- Dexascan results
- Calcium and Vitamin D test results
- Any other current lab test results
- NPI number of the ordering provider
Need Help? Call us at (954) 361-1000.
Plain Paper Form: You’ll need to print this form, fill in the instructions, and fax to us.
Fillable PDF: You can type in the required data on this form, but you’ll still have to fax to us when complete.