Get the free Occult Blood ABN Form - Parkview Health Laboratory
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Park view Health Laboratories 328 La Road Fort Wayne, IN 46825 260-373-9420 Patient s Name: Medicare # (ICN): ADVANCE BENEFICIARY NOTICE OF COVERAGE (ABN) Laboratory Test(s) NOTE: If Medicare doesn't
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How to fill out occult blood abn form
How to fill out occult blood abn form:
01
First, gather all the necessary information such as the patient's name, date of birth, and contact details.
02
Next, identify the healthcare provider who ordered the occult blood test and include their name and contact information on the form.
03
Fill in the date the form is being completed.
04
Indicate the patient's medical record number or any other identification number provided by the healthcare facility.
05
Specify the date the test was ordered by the healthcare provider.
06
Describe the reason for the occult blood test, including any symptoms or medical conditions that warrant the test.
07
Provide any relevant details about the patient's medical history or current medications that could impact the test results.
08
Identify the specific occult blood test being requested, such as a fecal occult blood test (FOBT) or an occult blood screen.
09
If required, provide information on any previous occult blood tests the patient has undergone.
10
Sign and date the form, verifying that the information provided is accurate and complete.
Who needs occult blood abn form:
01
Patients who are experiencing gastrointestinal symptoms such as abdominal pain, rectal bleeding, or unexplained weight loss may require an occult blood test.
02
Individuals with a personal or family history of colorectal cancer or polyps may be advised to undergo regular occult blood screenings.
03
Healthcare providers may also order an occult blood test for routine preventive care, especially for patients over the age of 50 or those at higher risk for colorectal cancer.
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