www.wisconsinlab.com Phone: (414) 774-8612 Fax:    (414) 453-7295	Wisconsin Viral Research Group Test Request Form	10437 Innovation Drive Suite 321 Milwaukee, WI 53226
Enclose completed form with sample.                                                                       Rev 01-2010
I.  Patient Information
Name (last, first):                                                                 Date of Birth:                          M/F
Address:                                                                                        Phone:
II. Ordering Physician Information: Please include a FAX number for result reporting
Name:                                                                                                   UPIN#:
Address:
FAX Results To:                                            Phone:                           Contact Person:
III. Payment Information: Please note: Our laboratory does not bill patients, patient's insurance or Medicare**
Payment by: (choose one)        Check           Money Order     Credit Card (fill out information below)
Name on Credit Card:
Credit Card Information: (circle one)          VISA      Master Card      Discover      American Express
Credit Card Number:                                                                                     Exp Date:
All self-paying patients will receive a standard HCFA insurance submission form for insurance purposes.
**Medicare Advance Beneficiary Notice These tests are not covered by Medicare unless you are an organ transplant recipient or a patient with HIV Disease.  I understand that Medicare will not pay for my testing.  _________________________________________________    Patient Signature
IV. Specimen Information: (circle one)   Blood  CSF  Bone Marrow       Other Date Collected ((Required)                                                                                         Phleb:
V. ICD-9 Code(s): Required (systemic complaint and/or diagnosis) 1)            2)             3)             4)
VI. Tests:      _____  HHV-6 Culture/Ag (#2000)            _____  HCMV Culture/Ag (#3000)                                   _____  Nested HCMV DNA PCR (#1400)     _____  Nested HHV-6 DNA PCR (#1100)                      _____  Nested EBV DNA PCR (#1200)        _____  HHV-7 DNA PCR (#1300)
Shipping Instructions: FedEx is our preferred shipper. Ship Monday through Thursday using the "PRIORITY OVERNIGHT - NEXT BUSINESS MORNING" shipping option.  Ship to: Wisconsin Viral Research Group 10437 Innovation Drive Suite 321 Milwaukee, WI 53226
For Lab Use Only  Received:                                         Accn #                                         Mailer