Repeat Order Form Unable to Service per Contract Rules-Order will be Cancelled Potential-Risk- A2A PMO Approval RequiredAdditional Note - We are servicing this patient with Male techs only 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/collectionBlood draw and urine specimen pickupSpecimen collection 13.0 Quantity Requested * 14.0 Date Requested * 15.0 Time Requested(If the Date Requested is today's date, please select a time at least 3 hours ahead of the current time) * 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM 16.0 Home Visit [Y/N] * YesNo 17.0 Emergency [Y/N] * YesNo 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] * YesNo plus1 Add minus1 Remove 29.0 Order Type * ROUTINESTAT 30.0 Ordering Facility Name * 1070 -Cardiology 1173 -Continuing Care-Palliative Cre 1190 -Dermatology 1330 -Endocrinology 1380 -Gastroenterology 1550 -HIV Clinic 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) * Unable to Service per Contract Rules-Order will be Cancelled Potential-Risk- A2A PMO Approval RequiredAdditional Note - We are servicing this patient with Male techs only If you are human, leave this field blank. Kaiser Permanente (Repeat) quantity Biweekly Invoice via Contract CONTACT US 1-800-493-3736 Ext 6 lab2go@a2a-logistics.com