Patient Name:

Date:

To Whom it May Concern,

I am the physician for the patient noted above and am writing to request coverage for the diagnostic Food Allergy/Sensitivity Test performed by Infinite Allergy Labs for my patient. I consider this test a medically necessary step in the diagnosis and treatment of my patient due to their medical history, and there is no in-network laboratory in my area able to provide comparable testing.


Food sensitivities cause a range of illness and symptoms, including skin rashes and chronic intestinal diseases. The Infinite Allergy Labs FAST Panel measures over 88 of the most common foods and additives. This yields many benefits, including uncovering which foods are causing inflammation and disease, developing a personalized nutritional guide, and improving a patient's state of health and energy levels. The test is the most sensitive food test available methods that detect both IgG, IgG4, IgE, and C3b/d antibodies and complement antigen together to determine the reactivity of each sample against a wide variety of food antigens using the most up to date technology.


Food elimination based on the Infinite Allergy Labs FAST Panel results has been shown to significantly reduce symptoms a patient is experiencing.

LABORATORY PERFORMING TEST:

Infinite Allergy Labs - a high complexity CLIA laboratory located at 3885 Crestwood Pkwy Suite 550 Duluth GA 30096.

CLIA ID#: 11D2142105, Phone: 1-833-FOODALLERGY www.infiniteallergyalabs.com


Physician Signature: