Molecular Diagnostics

Molecular Diagnostics
Lab Director: Ingerlisa W. Mattoch, MD

CLIA 06D1095628
6748 N. Franklin Ave., Loveland CO
Phone: (970) 635 – 1805
Fax: (970) 635-0032
PATIENT INFORMATION
M F
Patient: _____________________________ ____________________________   DOB: ______________
First Name Last Name
Social Security Number: __________________________ Phone Number: ____________________________
Address: __________________________________ _________________________________ _________ __________

Street City State Zip
SPECIMEN INFORMATION
Specimen: Source: ______________________________ Date Collected: __________ Time Collected: __________
ICD-10 Code Diagnosis Code(s): ___________________________________________________________________
PROVIDER INFORMATION
Ordering Provider: ______________________ _________________________ ___________________________

First Name Last Name NPI Number
TEST/PANEL SELECTION: Multiple panels may be selected for specimen provided if there is sufficient quantity and the
specimen is appropriate for each panel.
Wound Pathology Options □ Urinary Tract Infection

(Please check to add for UTI)
□ Basic Wound Pathology □ Antibiotic Resistance Panel
or
□ Wound Pathology with Staphylococcal □ Respiratory Pathogen
Resistance Genes
□ Gastrointestinal Pathogen
*See reverse page for test menu
After selecting bill class, attach a face sheet and insurance card copy containing the patient and
BILLING INFORMATION
insurance information requested below.
Bill Class:  Medicare  Medicaid  TriCare  Worker’s Compensation □ Commercial
Insurance Information Please attach a copy of all insurance cards
Primary Insurance: Policy/ID#: _______________________________ Group #: _________________________________
Subscriber: Name (if other than patient): _____________________________ Relationship to patient: __________________
Insurance Company: Name: __________________________________ Phone Number: ______________________________
Is this a Worker’s Comp claim?  Yes  No Date of Injury: ______________ Adjusters Name/phone: ___________________
Ordering Provider Signature: ________________________________________ Date: ___________________

Urinary Tract Infection Menu Wound Pathology Respiratory Pathogen Testing
Acinetobacter baumannii Acinetobacter baumannii Menu
Citrobacter freundii Bacteroides spp. Viruses
Enterobacter aerogenes Citrobacter freundii
Adenovirus
Enterobacter cloacae Clostridium novyi/septicum
Coronavirus 229E
Enterococcus faecalis Clostridium perfringens
Coronavirus HKU1
Enterococcus faecium Enterobacter aerogenes
Coronavirus NL63
VRE - Vancomycin-resistant Enterobacter cloacae
Coronavirus OC43
Enterococci Escherichia coli Enterococcus faecalis
Influenza A
Klebsiella spp. Enterococcus faecium
Influenza A/H3
Morganella morganii VRE - Vancomycin-resistant
Influenza A/2009-H1
Proteus mirabilis Enterococci
Influenza B
Proteus vulgaris Escherichia coli
Human Metapneumovirus
Pseudomonas aeruginosa Kingella kingae
Human Rhinovirus/Enterovirus
Staphylococcus saprophyticus Pseudomonas aeruginosa
Parainfluenza 1 (PIV1)
Staphylococcus aureus
MRSA - Methicillin-resistant
Staphylococcus aureus
Panton-Valentine leukocidin
Respiratory Syncytial Virus
(PVL) gene
Bacteria
Staphylococcus lugdunensis
Bordetella pertussis
Streptococcus pyogenes (Group A)
Chlamydophila pneumoniae
Mycoplasma pneumoniae
Antibiotic Resistance Panel Wound Pathology with Gastrointestinal Pathogen

ß-LACTAMS Staphylococcal Testing Menu
Enzyme Class A ß-lactamases Resistance Genes Bacteria
CTX-M Group 1 Acinetobacter baumannii Campylobacter (jejuni, coli, and
CTX-M Group 2 Bacteroides spp. upsaliensis)
CTX-M Group 8/25 Citrobacter freundii Clostridium Difficile (toxin A/B)
CTX-M Group 9 Clostridium novyi/septicum
Plesiomonas shigelloides
KPC Clostridium perfringens
Salmonella
Enzyme Class B Metallo-ß-lactamases Enterobacter aerogenes
Enterobacter cloacae Yersinia enterocolitica
IMP Vibrio (parahaemolyticus, vulnificus,
Enterococcus faecalis
VIM Enterococcus faecium and cholera)
NDM Vancomycin-resistant Enterococci Vibrio Choleae
Enzyme Class C AmpC ß-lactamases Escherichia coli Enteroaggregative E. coli (EAEC)
FOX Kingella kingae Enteropathogenic E. coli (EPEC)
Enzyme Class D Oxacillinases Klebsiella spp. Enterotoxigenic E. coli (EPEC)
OXA-1 Morganella morganii Shigella/Enteroinvasice E. coli (EIEC)
OXA-48 Proteus mirabilis Parasites
Minor Extended-Spectrum ß-lactamases Proteus vulgaris Cryptosporidium
PER Pseudomonas aeruginosa Cyclospora cayetanensis
VEB Staphylococcus aureus
Entamoeba Histolytica
GES MRSA - Meth. resistant S. aureus
Giardia lamblia
Panton-Valentine leukocidin gene
MACROLIDES Viruses
Staphylococcus lugdunensis
ermB Streptococcus pyogenes (Group A) Adenovirus F 40/41
FLUOROQUINOLONES Staphylococcal Resistance Genes: Norovirus GI/GII
qnrA Aminoglycoside Rotavirus A
qnrS Cephalosporin Sapovirus (I, II, IV, V)
Erythromycin/Clindamycin
Methicillin
Tetracycline

Molecular Diagnostics

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Molecular Diagnostics

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Molecular Diagnostics

Lab Director: Ingerlisa W. Mattoch, MD

Social Security Number: Phone Number: __

Address: ______ _ _ ______

Specimen: Source: __________________ Date Collected: Time Collected:

ICD-10 Code Diagnosis Code(s): ___________________________________________________________________

Ordering Provider: __________ _ _______________

Wound Pathology Options □ Urinary Tract Infection

Bill Class:  Medicare  Medicaid  TriCare  Worker’s Compensation □ Commercial

Insurance Information Please attach a copy of all insurance cards

Primary Insurance: Policy/ID#: _ Group #: ___

Insurance Company: Name: ____ Phone Number:

Ordering Provider Signature: ______________________ Date: _

Antibiotic Resistance Panel Wound Pathology with Gastrointestinal Pathogen

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