Requisition Form

Jivora Health — Test Requisition Form
Jivora Health
Advanced Tick-Borne Testing, Made Simple
T: 866-660-5486  |  [email protected]  |  jivora.co

TEST REQUISITION FORM

DOMESTIC USE ONLY  ·  BD-F-018v20 08-18-2025
Processing may be delayed if incomplete: PATIENT INFO (demographics, prepayment, signature) & PHYSICIAN INFO (address, DX codes, NPI, signature) are required.
1  ·  Patient Information
2  ·  Billing Information IGeneX does NOT bill Health Insurance, Medi-Cal, or Medicaid
✓ YES — I have Medicare (Part B) Coverage
Attach Medicare card copy & complete Medicare Patient Insurance Information Form
✗ NO — I do not have Medicare (Part B) Coverage
Pay by Check
Pay by Credit Card
Visa, MasterCard, Discover, or Amex ONLY — No CareCredit

By signing, I accept financial responsibility and authorize any credit card charge. I understand I am responsible for submitting my own insurance claim.

3  ·  Referring Physician / Laboratory Information
Only medically reasonable and necessary tests for Medicare patients will be reimbursed. Ordering unnecessary tests may be subject to civil penalties under the False Claims Act.

If signature not available, please attach Physician's Prescription.

4  ·  Drawing Laboratory Visit igenex.com for specimen shipping & handling info
5  ·  Select Test Panel(s) Click a panel to select it for this requisition
* All tests performed by ArminLabs, CAP- & CLIA-certified. Results for informational purposes only; not a medical diagnosis.
Qty ordered: 0 unit(s)
Estimated Total$0.00

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