Submit the completed form by mailing it to Alcala Labs, 3703 Camino Del Rio South 100-A, San Diego, CA 92108. Alternatively, fax the form to (619) 450-5870 or submit it online through the lab's submission portal. For queries, contact Alcala Labs at the provided phone number. Ensure that all sections are accurately filled out before submission to avoid processing delays.

Ensure to check any updates or renewals of this form for the years 2024 and 2025 to stay compliant with medical regulations.

The purpose of this form is to request necessary blood count and chemistry tests for patient diagnosis and treatment. By accurately completing this form, physicians can ensure that lab tests are processed efficiently, allowing for timely diagnostics and treatment plans. It is also used to provide insurance companies with the required details to process lab test claims.

• 1. Physician & Practice Information: Provide the physician's and practice's name, address, and contact details. Ensure all required fields are completed.
• 2. Patient Information: Include patient’s last and first name, date of birth, and social security number. Accurate information is crucial for correct lab test processing.
• 3. Diagnosis Codes (ICD 10): Enter the appropriate diagnosis codes related to the patient's condition. It is important for medical necessity verification.
• 4. Panels and Profiles: Select the required blood count and chemistry panels. Options include CMP, CBC, lipid profile, among others.
• 5. Individual Tests: Choose specific tests needed, such as glucose, creatinine, or thyroid-related tests. Ensure the right tests are selected for accurate diagnostics.
• 6. Specimen Information: Provide details about the specimen collected, including date and time of collection and fasting status.
• 7. Authorization & Attestation: Patient and physician signatures are required to authorize the tests and billing. Include any additional necessary authorizations for insurance purposes.

Failure to submit this form can result in delayed or denied lab tests and diagnostic procedures, which may affect patient treatment plans.

• Treatment Delays: Without timely test results, necessary treatments may be postponed.
• Insurance Issues: Lack of proper documentation can lead to issues with insurance claims and reimbursements.
• Inaccurate Diagnoses: Incomplete information might lead to incorrect or missed diagnoses, affecting patient health outcomes.

• 1. Routine Checkups: Physicians can use this form during routine checkups to request standard blood and chemistry panels.
• 2. Treatment Monitoring: Helps monitor patient response to ongoing treatments by requesting relevant lab tests.
• 3. Diagnosis Confirmation: Used for confirming diagnoses by conducting necessary blood and chemistry tests.
• 4. Pre-surgical Assessments: Ensures patients are fit for surgery by conducting essential blood work and chemistry panels.
• 5. Insurance Claims: Provides necessary information for insurance claims related to lab tests.