Billing Information
For accurate billing reports, the client must furnish the information required on the requisition form. Patient’s full name and address; date of birth, and referring physician UPIN are the basic information necessary. Any questions regarding billing, please call our facility.


Bill Medicare – Check “Bill Medicare” on the test request
- Name and address of patient
- Medicare number/ Social Security number
- Date of birth
- ICD9 diagnosis code
- Referring physician’s UPIN
- Patient signature on the requisition, copy of Medicare card
Bill Medicaid – Check “Bill Medicaid” on the test request
- Name and address of patient
- Medicaid number/ Social Security number
- MediPass Number
- Date of birth
- ICD9 diagnosis code
- Referring physician’s UPIN
- Patient signature on the requisition, copy of Medicaid card
Bill Physician – Check “Bill Physician” on the test request
- Name of patient
Bill Patient – Check “Bill Patient” on the test request
- Name and address of patient
- Name of responsible party if other than patient.
- Telephone number of the patient.
- Social Security number
Bill Insurance
- Name and address of patient
- Name of responsible party if other than patient
- ID Number
- Group Number
- ICD9 diagnosis code
- Employer name
- Date of birth
- Copy of insurance card