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Solstas Lab Partners Group, LLC (Solstas), a Quest Diagnostics Company

Physician Authorization Form for Custom Panels


(Single Physician)
FOR TESTING PERFORMED AT Solstas Lab Partners Group, LLC (Solstas), a Quest Diagnostics company
Greensboro-Federal Drive

CLIENT NAME: Arthritis & Osteoporosis Center________ CLIENT ACCOUNT NO: ____993423_______________
[ X ] NEW PANEL [ ] CHANGE TO EXISTING PANEL TODAYS DATE: 11-18-2015

Custom
Panel Name

Custom
Panel
Order
Code

Test Name/Test Order Code

Medicare
CPT
Code

Patient
Price

Maximum
Allowable
Medicare
Reimbursement

Fibro Panel
ANA, IFA Reflex Titer
Angiotensin 1 CE
GGT
Hep B Core Ab IgM
Hep B Core Ab Total
Hep. B SAG
Hep. C Ab
HIV Ag/Ab, 4th Gen
w/reflexes
Iron
TIBC
LDH
Phosphorus
Serum Protein Electrophoresis

23903
23258
23130
23580
23570
23560
23620
23630

86038
82164
82977
86705
86704
87340
86803
86703

83
93.50
50.50
131.50
79
79
90.50
104

16.45
15.45
9.80
16.03
13.05
13.43
19.42
18.66

23310
23315
23190
23170
59550

41.50
39
50.50
29
99

8.81
11.90
8.21
6.45
4.99, 14.61

Rheumatoid Factor
RPR Reflex to T. Pallidum Ab,
Total
T3, Uptake
T4 Total
TSH

23890
23940

83540
83550
83615
84100
84155,
84165
86431
86592

51.50
37

7.72
5.81

23270
23265
23280

84479
84436
84443

46.50
39
59

8.81
9.35
22.87

Page 1 of 2

2014 Quest Diagnostics Incorporated.


All rights reserved.

Solstas Lab Partners Group, LLC (Solstas), a Quest Diagnostics company

Physician Authorization Form for Custom Panels


Single Physician Form
NOTES:
The CPT codes provided are based on AMA guidelines and are for informational purposes only. CPT coding is the
sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.
When the Medicare fee schedule amounts for the components of these custom panels exceeds Solstas, patient price,
Medicare reimbursement is limited to the patient price shown on this form. Medicaid reimbursement is typically
the same as or lower than Medicare reimbursement. Reimbursements from other third party payers may be
greater than, the same as or lower than Medicare reimbursement.
When you order testing for any Medicare or Medicaid patient, you should only order those tests that are medically
necessary for the diagnosis and treatment of the patient. Certain third party payers have similar medical necessity
requirements. Using a custom panel may result in ordering certain tests that are not medically necessary for the
patient. Accordingly, where not all of the tests in the custom panel are medically necessary for the diagnosis and
treatment of the patient, Solstas provides you with the option of ordering any of the tests in the custom panel
individually or ordering a less inclusive panel. The Department of Health and Human Services takes the position
that a physician who orders medically unnecessary tests for any Medicare or Medicaid patient may be subject to
civil penalties.
This will confirm that I have reviewed this Physician Authorization Form for Custom Panels, including the information listed
above as to the custom panels and the Notes. With respect to the custom panels, I understand the following:
1. the components of the custom panels listed above;
2. the Medicare reimbursement for the tests included in each panel;
3. these custom panels will appear as separate check-off items on my requisition;
4. by selecting the test order code for a custom panel, I am electing that all components included in that panel
be performed;
5. the components of a custom panel may be charged separately to Medicare, Medicaid and other third party
payers using the CPT codes indicated; and
6. that I always have the option to order separately one or more of the individual components of each panel.
IMPORTANT: In the event that additional physicians become members of my practice, I will ensure that these physicians
receive and review a copy of this form and understand each of items 1 through 6 and will contact Solstas to obtain a Physician
Practice Group Form to be signed on behalf of those physicians that become members of my practice.

Physicians Signature

NPI #

Date

___________________________________________
Print Name
Page 2 of 2

2014 Quest Diagnostics Incorporated.


All rights reserved.