Provider Covid-19 Lab Order Form

Valley Medical Laboratory Covid-19 Specimen Collection and Testing Order Form
Patient Information (please complete ALL fields or attach face sheet for a valid order)
Section A
Upload Face Sheet

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If you attach a face sheet, then you can skip to Section B.
Patient ID:
First:
Last Name:
MI:
Date of Birth

Month Day Year
Date
Sex:
Phone Number (mobile preferred)

Area Code Phone Number
Secondary Phone

Area Code Phone Number
Patient Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Carrier:
ID #:
Group #:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Section B
Dx (ICD)
Provider Name & Title: *
NPI: *
Clinic Name *
Clinic Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number: *

Area Code Phone Number
Fax Number *

Area Code Phone Number
Authorization – Please Sign and Date
Physician/Referral Provider Signature *

Clear
Order Date *

Month Day Year
Date
When you submit this form it will be automatically sent to the Valley Medical and Wellness Laboratory to complete. Next, please select a date and time for you patient to come in for testing. Thank you!
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Valley Medical Laboratory Covid-19 Specimen Collection and Testing Order Form