Infertility Panel Forms

Please include a completed requisition form, and billing information form with specimens sent for testing. Work will not begin on samples that arrive without the completed paperwork.

Infertility Panel Requistion Form

Billing Information Form

ABN Waiver--required for Medicare patients, refer to Medicare approved diagnosis list.

Tricare Waiver--required for Tricare patients, refer to Tricare approved diagnosis list.

Our forms are in Adobe Acrobat PDF format. You can download Adobe free at the following link.http://www.adobe.com/products/acrobat/readstep2.html