Reliancemedlabs
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MLD FORM
REQUISTION FORM
17774 Preston Road, Dallas, TX 75252
Email :Info@reliancemedlabs.com
CLIA#: 45D2099319
Phone #: (972) 925-0723
Fax#: (866) 230-5899
Please send patient’s demographics and copy of insurance card with requistion
Patient Information
Patient’s Last Name:
Patients First Name:
Patient’s Date of Birth:
Patient’s Social Security #:
Patient’s Address City, State, Zip Code:
Patient’s Phone Number:
Patient’s Email Address:
Patient’s Gender:
MALE
FEMALE
Does Patient have insurance?
YES
NO
Primary Insurance Provider:
Secondary Insurance Provider:
Member ID #:
Group ID #:
Member ID #:
Group ID #:
For Self Pay – Who do we contact for payment?
Contact name
Contact Phone Number
Physician and Facility Information:
Facility Name:
Authorizing Physician’s Name:
Facility Address, City, State, Zip Code:
Authorizing Physician’s NPI #:
Facility Phone Number:
Physician’s Phone Number:
Facility Fax Number:
Physician’s Fax Number:
MedLife Diagnostic Services: Mobile X-rays, Ekg, Echo-cardiogram, and Ultrasounds (Place and X in the box next to the ordered test and circle the L or R Site when appropriate)
Xrays
Chest 1V
Chest 2V (AP& LAT)
Ribs
Spine: Cervical C-Spine
Spine: Thoracic T-Spine
Spine: Lumbar L-Spine
Pelvis
Coccyx, Sacrum
Facial Bones (3 view)
Skull
Shoulder (L)
Shoulder (R)
Humerus (L)
Humerus (R)
Elbow (L)
Elbow (R)
Forearm (L)
Forearm (R)
Wrist (L)
Wrist (R)
Hand (L)
Hand (R)
Fingers(L)
Fingers(R)
ABDOMEN
Facial Mandible (Jaw)
KUB
Hip (L)
Hip (R)
Femur (L)
Femur (R)
Heel(L)
Heel (R)
Knee (L)
Knee (R)
Tibia/Fibula (L)
Tibia/Fibula (R)
Ankle (L)
Ankle (R)
Foot(L)
Foot(R)
Toes(L)
Toes(R)
Others
Ultrasounds
Upper Extremity Arterial Doppler
Lower Extremity Arterial Doppler
Upper Extremity Venous Doppler
Lower Extremity Venous Doppler
Abdomen Complete
Others
Cardiology
Ekg
2D Echo-cardiogram
Others
Please complete all form fields, incomplete requisition form will delay results
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