Add-Ons Form - cpl_addons

Instructions for Website Add-Ons

The interactive add-on form is used to request additional test(s) be added to a sample with an assigned accession number in the laboratory. Select specimens are held for 7 days. Contact your local CPL Customer Service Department for an add-on that has reached the 7th day.

Requests will be processed Monday – Friday 8AM - 5PM Central Standard Time.

For immediate assistance or STAT requests, contact your local CPL Customer Service Department.

If you are not the original ordering provider and your account number is known, enter your account number in the appropriate section.

If you do not have an account number or do not know the account number, contact your local Customer Service Representative.

Incorrect or missing information may result in add-on processing delays.

A Customer Service Representative will contact you for requests requiring clarification or about a rejection.

1.) PHYSICIAN AND PATIENT DETAILS

Information provided must match the previous order. Patient name, date of birth and sex are required. A requesting physician adding tests that was not the original ordering physician must fill out the section at the top of the form.

2.) BILLING DETAILS

Please select one of the three billing options. When choosing Insurance Bill, provide the appropriate ICD-10 codes.

Note: If none of the options are chosen, the billing will default to Client Bill.

3.) ADDITIONAL TESTS REQUIRED

Provide the Test Name and the appropriate corresponding Test Code.

Note: Any test code and test name mismatches will result in delays.

Visit the CPL Test Directory if you need assistance determining the Test Name or the Test Code: https://www.cpllabs.com/clinicians/test-directory/

Contact your local Customer Service Department to add-on more than 6 tests.

4.) CLIENT CONTACT DETAILS

Complete Client Contact information is required. This information will be used to contact you if any clarification of a request is needed or to relay information about the request.

CPL Add-on requisition

Account Number *

Requesting Physician *

Accession Number *

Original Date of Collection *

If known, do you wish to enter a Time of Collection?

Yes No

Patient Details

First Name *

Last Name *

Date of Birth *

Sex *

Male Female

Fasting

Yes No

Billing

Choose one of the following billing options *

Client Bill

Patient Bill (provide address below if original accession is patient bill)

Insurance Bill (provide information below if original accession is insurance bill: ICD-10 Diagnosis codes() required))

Patient Billing Address

Address *

City *

State *

Zip Code *

Insurance Information

ICD10-1

ICD10-2

ICD10-3

ICD10-4

ICD10-5

ICD10-6

ICD10-7

ICD10-8

ICD10-9

ICD10-10

Responsible Party

Name

Address

City

State

Zip

Medicare Number

Medicaid Number

Primary Insurance

Name

City

State

Zip

Member ID

Group Number

Phone

Test Codes

Test Code *

Test or Profile Name *

Client Contact

Client Contact Name (First and Last Name) *

Phone Number *

Fax Number*

Tests are required.