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Order Labs
Back to A2A Logistics
Tests Formulary
Create an Account
My account
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Product Form
Patient Information
1.0 Patient Last Name
*
2.0 Patient First Name
*
3.0 Patient MRN#
*
4.0 Patient DOB
*
5.0 Street Address (Home)
*
6.0 City
*
7.0 State
*
8.0 Zip
*
9.0 Patient Special Instructions – Quality of Care Notes
*
10.0 Patient Phone Number (Cell)
*
11.0 Patient Phone Number (Home)
Order Information
12.0 Select Service
*
Blood draw/collection
Blood draw and urine specimen pickup
Specimen collection
13.0 Quantity Requested
*
14.0 Date Requested
*
15.0 Time Requested
*
12
1
2
3
4
5
6
7
8
9
10
11
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00
05
10
15
20
25
30
35
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45
50
55
AM
PM
16.0 Home Visit [Y/N]
*
Yes
No
17.0 Emergency [Y/N]
*
Yes
No
Select If Pickup Location Same as Patient Information
18.0 Specimen Pick Up Street Address
*
19.0 Specimen Pick Up City
*
20.0 Specimen Pick Up State
*
21.0 Specimen Pick Up Zip
*
22.0 Ordering Facility Dept
*
23.0 Ordering Facility Phone
*
24.0 Requestor Email
*
25.0 Requestor: First Name
*
26.0 Requestor: Last Name
*
Alternate Requestor Email
Alternate Requestor: First Name
Alternate Requestor: Last Name
plus1
Add
minus1
Remove
27.0 TEST REQUESTED
*
Pickup
28.0 FASTING [Y/N]
*
Yes
No
plus1
Add
minus1
Remove
29.0 Order Type
*
ROUTINE
STAT
30.0 Ordering Facility Name
*
1070 -Cardiology
1173 -Continuing Care-Palliative Cre
1190 -Dermatology
1330 -Endocrinology
1380 -Gastroenterology
1550 -HIV Clinic
1578 -Oncology
1590 -Internal Medicine
1679 -Mental Health/Psych_Trnsgndr
1690 -Nephrology
1710 -Neurology
1830 -Oncology
1970 -Pediatrics
2230 -Primary Care
2238 -Primary Care - APC Float
2262 -Primary Care- HC Team 1
2263 -Primary Care- HC Team 2
2264 -Primary Care- HC Team 3
2290 -Pulmonology
2350 -Rheumatology
3043 -Ambulatory Infusion Center
3741 -Home Health - Int - Gennursing
3744 -Home Health - Int - Patientsvc
3760 -Hospice - Internal - Nursing
3774 -Medical House Calls NP
3775 -Home Infusion Therapy
3805 -Palliative Care - Other
3819 -Continuing Care_Leadership
4072-Clinical Pharm AntiCoagulation
31.0 Ordering Facility General Ledger Code
*
32.0 Ordering Physician First Name
*
33.0 Ordering Physician Last name
*
34.0 Ordering Physician Title
*
35.0 Order Notes
*
Accounting / Billing
36.0 Confirm General Ledger Code
*
37.0 National User Identification (NUID)
*
If you are human, leave this field blank.
Kaiser Permanente quantity
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CONTACT US
1-800-493-3736 Opt#5
FAX: (973) 787-9197
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