Nationwide Access To Diagnostic Lab Tests

Phone: 1-888-531-2030 | Fax: 1-855-345-5222

Refer a patient

For providers only.
Please use this form to submit an referral for lab tests. LaboratoryAssist will reach out to the patient for scheduling.
Lab Tests
Lab Tests
Test Code (Optional) Test Name

Please list lab tests. Include test numbers if known
Test codes type?*
Diagnosis
Diagnosis
Hidden
Diagnosis Codes Selected
Additional Instructions
Additional instructions for our schedulers
Ordering Provider
Provider Name*
Data presented from NPI database. You can update the address on the next page.
Please verify that provider data is accurate
Hidden
NPI
Provider Name
First Last
Provider Address
Street Address Address Line 2 City State Zip Code
Provider Phone
Provider Fax
If no fax number is provided, provider will need to obtain reports from the patient.

Patient Information
Patient Name*
First Last
Date of birth*
MM slash DD slash YYYY
Gender
- Male
- Female
Address
Street Address Address Line 2 City State Zip Code
Phone*
Please ensure it is accurate and you are reachable at this number.
Email
Note to providers
Patients must be informed to call LaboratoryAssist at 888-531-2030 to schedule their appointment
Sign Order
Please certify*
- I am electronically signing this order for lab tests. I acknowledge and agree that submission creates an electronic signature that has the same legal effect and validity as my written signature.
Please confirm*
- Patient is aware about this referral and has been informed to call LaboratoryAssist at 888-531-2030
Name
This field is for validation purposes and should be left unchanged.

Fax Referral

Fax a completed referral to
855-345-5222.

Upload Referral

Submit a referral using the secure upload form.

LaboratoryAssist Program
Assist Health Group
2100 Valley View Ln,
Suite #490,
Farmers Branch, TX 75234

Phone	: (888) 531-2030
Fax	: (855) 345-5222

Hours : Mon-Fri 8-5pm (CST)

All-inclusive Rates Nationwide
$6	CBC Complete Blood Count
$7	CMP Comp Metabolic Panel
$7	Renal Function Renal Function Panel
$7	Lipid Panel w or w/o reflex
$7	Blood Draw Per visit

Test Code (Optional)	Test Name