*<orderinfo.requisitionnumber>*	
Network Node	CPLOIR02	Requisition #	<orderinfo.requisitionnumber>	
Order Priority	<orderinfo.priority>	Collection Date	<orderinfo.collectiondate>	
<PersonalInfo.LastName>  <PersonalInfo.FirstName>  <PersonalInfo.MiddleInitial>
<PresentAddress.Address><PresentAddress.Apt#>
<PresentAddress.City>  <PresentAddress.State>  <PresentAddress.Zip>
<PersonalInfo.DOB>  <PersonalInfo.Sex> 
<ReqProvider.Name>	Account	<orderinfo.cplaccountnumber>	
	<orderinfo.servicefacilityphone>
<orderinfo.servicefacilityname>
<orderinfo.servicefacilityaddress>
<orderinfo.servicefacilitycity>,<orderinfo.servicefacilitystate>,<orderinfo.servicefacilityzip>	
Bill	<PrimaryInsurance.InsuranceCompany>
To:	<PrimaryInsurance.ClaimsAddress>
	<PrimaryInsurance.City>  <PrimaryInsurance.State>  <PrimaryInsurance.Zip>	o 920 	Venipuncture CPL
o 919	Venipuncture
o 997	Verbal Diagnosis
o 9999	Verbal Order
o 989	Pt Decline	o 925 	Finger/Heel Stick	PSC ID
o 922	UR Vol Mass	   _______
o 996	Standing Order	               Phlab ID
o ABN	o Attachments                ______
o 9864	ABN Option 2	
PLEASE COMPLETE INFORMATION BELOW	
Bill To				
Client  	Patient	Primary Insurance	Secondary Insurance Medicare	
Policy Holder Name	Address	City, State, Zip	Evening Phone	
<PrimaryInsurance.InsuredName>				
Policy ID	Ordering Physician NPI	
<OrderInfo.ProviderSignature>	
<PrimaryInsurance.PolicyNumber>	<ReqProvider.NPI>		
	Physician’s Signature	
Primary Insurance Group	Date of Injury or Onset of Illness	Authorization #		
<PrimaryInsurance.GroupNumber>				R 20a	
Secondary Insurance Name	Address	City, State, Zip	Phone	
<SecondaryInsurance.InsuranceCompany>	<SecondaryInsurance.ClaimsAddress>	<SecondaryInsurance.City>  <SecondaryInsurance.State>  
<SecondaryInsurance.Zip>	<SecondaryInsurance.Phone>	
Policy Holder Name	Policy ID	Group		
	<SecondaryInsurance.PolicyNumber>	<SecondaryInsurance.GroupNumber>		
	ICD-10	ICD-10	ICD-10	ICD-10	ICD-10	ICD-10	ICD-10	ICD-10	
ICD-10	<OrderInfo.Diagnosis1>	<OrderInfo.Diagnosis2>	<OrderInfo.Diagnosis3>	<OrderInfo.Diagnosis4>					
PANELS & TESTS ORDERED INCLUDING ADDITIONAL INFORMATION QUESTIONS	

<OrderInfo.Service1>
 <OrderInfo.Service2>
 <OrderInfo.Service3>
<OrderInfo.Service4> 
 <OrderInfo.Service5>
 <OrderInfo.Service6>
 <OrderInfo.Service7>
 <OrderInfo.Service8>

----------------------------------------------------- Additional Clinical Information ----------------------------------------------------------------

<Orderinfo.Comments>
<Orderinfo.Aoe>