Directory of Services - Hitachi Chemical Diagnostics

ALLOSReference LaboratoryReference #Patient (Last, First, MI)AddressCitySexCollection DateDate of BirthBill To:ICD-9 Code(s)SS NumberPhone( )Freeze Date:Thaw Date:Insurance (Attach front and back copy of card)No Medicaid or Medicare1. 2. 3. 4.HITACHI CHEMICAL DIAGNOSTICS, INC.630 Clyde Court, Mountain View, CA 94043Phone: (800) 272-6278 Fax: (650) 969-2745Patient Payment Agreement:I acknowledge that if my insurance denies payment, I agreeto be personally and fully responsible for payment of anyoutstanding balanceFor Lab Use OnlyRequesting PhysicianUPIN#Provider #Physician SignatureGroup/Laboratory NameAddressCityStateZipPhone #Fax #Bill To: PhysicianLaboratoryPatient Pre-Pay: Include Check or Credit Card onlyCheck payable to Allos Reference LaboratoryPayments Visa ® Master Card ®Card NumberPrint Name on CardExpiration DateSignatureDateSignatureFax Report To:_____________________________Accession #IgE PanelsRequire 2ml serum per panel*(36 Allergen, Specific IgE Assay)Additional Individual Allergens1402 Eastern Combination1418 Moderate Food1404 Northeastern Inhalant1405 Northwestern Inhalant1406 Pediatric Combination1407 Southeastern Inhalant1408 Southern Combination1409 Southwestern Inhalant1410 Western Combination1411 Western Inhalant________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Specimen for Split Sample Comparison Testing:PLEASE INCLUDE YOUR RESULTS WITH THE SERUM SAMPLE*Optigen ® Universal Specific IgE panelRequires only 0.5 ml serum(20 Allergen Specific IgE Assays)3001 Optigen ® Universal 20Order Additional Supplies:Kits to MAIL Samples to Allos Labs10 20 Specify # _________Extra Requisitions: Quantity __________White - ARL Laboratory Canary - Billing Pink - Client Rev. 9/10