COVID Drive-up Testing

Covid PCR Collection Requisition

CM will call the family to schedule testing
Please allow 48-72 hours following testing for results
Questions? Please call (913) 696-8378

PLEASE COMPLETE ALL BOXES.
MISSING OR INCOMPLETE INFORMATION WILL PREVENT SCHEDULING

Patient’s Name: Last

First

Middle

Address

City

State

Zip

Phone

Alternate Phone

Email Address

Billing

Self-pay

Insurance

Patient is:

Child

Self

Other

Insurance: Attach copy of card (both sides) OR complete the following

Attach Insurance Card Front

Upload No File Chosen

Attach Insurance Card Back

Upload No File Chosen

Attach Parent / Caregiver ID

Upload No File Chosen

Subscriber: Last name, First name, Middle initial

Employer

Primary insurance: Name & policy number

Secondary insurance: Name & policy number

Location:

Blue Valley

6750 W 135th Street
Overland Park, KS 66223

Northeast side behind building in parking lot (follow blue sign directions)

East

20300 E Valley View Pkwy
Independence, MO 64057

Front of building in circle drive (follow blue sign directions)

North

501 NW Barry Rd
Kansas City, MO 64155

South side behind building in parking lot (follow blue sign directions)

Broadway

3101 Broadway Street
KC, MO 64111

PL2 in parking garage (enter from Broadway or 31st street)

Mark all applicable

Asymptomatic (No symptoms but need negative test result to return to work, school, sports or daycare)

Asymptomatic exposure (No symptoms but in contact with someone with COVID-19)

Symptomatic (Showing signs of illness)

Mark all symptoms:

Cough

Fever

Shortness of breath

Other

MEDICAL NECESSITY REGULATIONS: at the government’s request, the Lab would like to remind all physicians that when ordering tests expected to be paid under federal health care programs, such as Medicare and Medicaid, the testing must meet the following conditions: (1) included as covered services, (2) reasonable, (3) medically necessary for the treatment and diagnosis of the patient and (4) not for screening purposes.

Printed Name

I acknowledge the above represents my electronic signature.

Date

COVID Drive-up Testing

Covid PCR Collection Requisition

PLEASE COMPLETE ALL BOXES. MISSING OR INCOMPLETE INFORMATION WILL PREVENT SCHEDULING

Location:

Mark all applicable

LOVE WILL find answers

PLEASE COMPLETE ALL BOXES.
MISSING OR INCOMPLETE INFORMATION WILL PREVENT SCHEDULING