Allergy Testing - NHPRI.org

Member Information
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Member's ID#*
Member's DOB*
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Date of service (if known)
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Member's Name*
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Facility Information
Place of service NPI*

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Place of Service for Test*
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Ordering MD*
Phone #*
Fax #*
Contact Name*
Email address in order to receive confirmation of request receipt*

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Clinical Information
Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*
Diagnosis ICD 10 Diagnosis Code

Example ICD 10 Diag Code: Z87.890
Rationale for Test*
Test Requested*
Test Requested *
- Full Inhalant/Respiratory Panel
- Full Food Panel
- > food/inhalant panel in 12 months
- Total IgE
- Allergen specific IgE: Qualitative, multi-allergen screen (dipstick, paddle or disk)
Attach Clinical*
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Signature of Treating Physician*
Signature Date:*
Request Method*
Request Method *
- Standard
- Expedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.
  Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.
Attach additional Clinical documents for Expedited request*
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Signature of Physician or Licensed Provider (Required for Expedited request)*
Signature Date:*
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Diagnosis	ICD 10 Diagnosis Code

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