• 1) ACCOUNT INFORMATION 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • 2) ORDERING METHOD 
    • Please select an option*
    • 3) REPORT DELIVERY METHOD 
    • Please select an option*
    • 4) ACCOUNT CONTACT INFORMATION 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • 5) CLINIC PAYOR MIX 
    • Please select an option
    • 6) SPECIMEN ORDER TYPE 
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    • *CPT 80305 and 80307 (Presumptive Testing) cannot both be performed and billed on the same date of service. Provider must communicate utilization of In-Office screens (POC cups).*
    • 7) PROVIDER ACKNOWLEDGEMENT 
    • 1) I hereby request and authorize Southwest Labs to process specimens from my practice. I further acknowledge and understand the following: 2) I understand that I have the choice to order any or allSouthwest Labs laboratory tests individually at any time. 3) I agree to order testing only when I have determined that each individual test requested, regardless of whether it is ordered individually or aspart of a panel, is medically necessary for that specific patient, as I have documented in that specific patient's chart. 4) I agree to provide diagnosis codes, defined to the highest level of specificity foreach test that I order to confirm medical necessity and to enable Southwest Labs to bill an insurance company on behalf of my patients. 5) I may only order those tests that I believe to be medicallynecessary for each individual patient. 6) Regarding toxicology testing, I understand that, according to Medicare, "Confirmation of drug screens is indicated when the result of the drug screen is differentthan that suggested by the patient's medical history, clinical presentation, or patient's own statement." 7) I understand that the Office of Inspector General (OIG) has cautioned "Using a customized profilemay result in the ordering of tests which are not covered, reasonable or necessary" and that "Only tests that are medically reasonable and necessary for the diagnosis or treatment of a Medicare orMedicaid patient will be reimbursed. The Office of Inspector General takes the position that a physician who orders medically unnecessary tests for which Medicare or Medicaid reimbursement is claimedmay be subject to civil penalties under the False Claims Act." 8) I am aware that Southwest Labs has available a technical director to assist me, if I request, to ensure that appropriate tests are ordered. 9) Allpaper requisitions and electronic orders will bear my signature, either in ink or in electronic format. I will provide an electronic signature to Southwest Labs and authorize their use of such for my laborders. 10) I understand that by signing this document, I am authorizing orders to be placed through Southwest Lab’s online provider portal. 11) I hereby give my explicit consent for the disclosure andtransfer of my treatment notes to Southwest Labs in instances where third-party payers, including insurance companies and health plans, require such documents for the purpose of processing andadjudicating claims related to my patient’s healthcare services.*
    • 9) PROVIDER(S) 
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