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Application Form for Miscarriages 2012
MEDICARE / MEDICAID BILLING
(Attach a CLEAR copy of both sides of the insurance card &
authorization as required)
FOR BILLING QUESTIONS CALL: (402) 559-5572
REPORTING RESULTS
SPECIMEN INFORMATION
Date and Time Collected:
Products of Conception » 1cm2 sterile tissue
p Fetal Tissue Source:
p Villi p Other:
Parental Blood » 2ml in sodium heparin tube
p Maternal Blood when available
p Paternal Blood *only required when conceived by egg donation
Ordering Physician:
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