BILL DOCTOR
BILL PATIENT / INSURANCE
INCLUDE OR ATTACH ALL BILLING INFO
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Vermont Dermatopathology |
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| Send specimens to: | VTDP Office contact: |
| VT. Dermatopathology | Phone: (802) 658-6269 |
| 50 Timber lane | Fax: (802) 860-4642 |
| South Burlingtion, VT 05403 | Toll-Free: (888) 864-4642 |
| www.vermontdermpath.com | |
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Requisition No. - |
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CHART NO. |
DATE COLLECTED |
TIME COLLECTED |
PHYSICIAN |
ICD 9 CODE |
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PATIENT NAME (LAST, FIRST, MIDDLE) |
S.S. NO. |
DOB |
SEX |
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PATIENT ADDRESS (INCLUDE APT. NO.) |
STATE |
CITY |
ZIP |
PHONE NO. |
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RESPONSIBLE PARTY (IF OTHER THAN PATIENT) |
SS # OF RESPONSIBLE PARTY |
EMPLOYER OF RESP. PARTY |
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INSURANCE NAME |
INSURANCE ADDRESS (INCLUDE CITY, STATE, ZIP CODE) |
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GROUP NO. |
POLICY NO. |
MEDICARE NO. |
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CLINICAL HISTORY AND PHYSICAL FINDINGS |
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SPECIMEN SITE |
CLINICAL DIAGNOSIS |
SPECIAL REQUESTS |
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REPORT HANDLING: ROUTINE RUSH |
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ADDITIONAL COPIES TO: _______________________________________________ FAX TO:______________________________________________________________
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