Dear Doctor

A federal regulation (final rule, federal register, Vol. 57. No. 40, February 28, 1992-Subpart J), now requires all laboratories to obtain written authorization for any lab test requested. Please review the following verbal test(s) or/and ICD-10 code(s) request made by your office on listed above patient and sign where indicated

Please return this form to the office. This completed form must be returned within 48 hours (part 58-1.7 (B) (1)). If you would like, the completed form may be given to your route service driver for delivery or faxed to 908-845-0253.