Allscripts Orderable Item Addition Master File

Allscripts Orderable Item Addition Master File
Complete this form when a new order needs to be updated or added to TouchWorks. All information is required, unless otherwise noted, and must be complete for this request to be honored.
Order Type (select one):
Order Name:
If this order is billable, please enter the CPT-4 Code:
Does the order have results that you need to record?
If so, enter them below (Please also indicate if the result is numeric or alphanumeric):
Order Information
Doest the order have question that should be answered before being filed?
Question #1:
Question #2:
Question #3:
Question #4:
Submitted By:

First NameLast Name
Date Submitted:

MonthDayYear
Phone Number:

Area CodePhone Number
Fax:

Area CodePhone Number
E-mail:
Internal Use
Status:
Status Details:
Completed By:

First NameLast Name
Date:

MonthDayYear
Should be Empty: