We cannot test your patient without this provider order and an appointment.
Submit the online referral form below or send a fax referral form to 303.270.2153. If possible, fax a copy of the patient’s insurance card or facesheet and photo identification to 303.270.2153.
Patients will be contacted for registration and scheduling. Patients MUST bring their photo identification and insurance (if available) and will sign consent upon arrival.
Note: Antibody testing (IgG and IgM) is generally not appropriate for acutely ill patients. Patients referred for antibody testing who have had new or worsening fever, cough, or shortness of breath within the last 2 weeks may be offered only the molecular diagnostic (swab) test and not the antibody test.
Provider Information
Provider First Name
Provider Last Name
Provider NPI
Colorado Medical License Number
Name of requesting office or facility
Provider Email
Provider Address
Provider Phone Number
Provider Fax Number
Patient Information
Patient First Name
Patient Last Name
Patient Gender
Patient Date of Birth
If child, parent's/guardian's name
Patient Address
Patients Phone Number
Patient Symptoms/ History
(check all that apply)
Insurance Name
Member ID/Policy Number
Group Number
Insurance Referral/Authorization Number
Comments
COVID-19 Diagnostic Testing Orders
Provider Acknowledgment / Electronic Signature
By typing your initials below, you attest that:
Initial Here
There are some validation issues on this page and we are unable to save your answers. To continue to the selected page without saving this page press 'Continue'.