OFDTK-54234

    ORAL FLUID DRUG TEST KIT REQUEST FORM ACCT#54234

    ORDERING PROVIDER INFORMATION

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    Name: Lauren McClairen

    NPI: 1457886129

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    Name: Rachel Hill

    NPI: 1043637101

    Address: 1370 Gateway Blvd, Ste 210, Murfreesboro, TN 37129

    Name: James McKenzie

    NPI: 1386952299

    Address: 1370 Gateway Blvd, Ste 210, Murfreesboro, TN 37129

    Name: Sarita Subedi

    NPI: 1962271015

    Address: 1370 Gateway Blvd, Ste 210, Murfreesboro, TN 37129

    PATIENT INFORMATION

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    *DOB:

    *GENDER: MALEFEMALE

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    PRESCRIBED MEDICATION

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    PATIENT INSURANCE

    *PATIENT HAVE INSURANCE
    YESNO

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    *PATIENT RELATIONSHIP TO INSURED

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    ORDERING PHYSICIAN INFORMATION

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