Requisition Form
To download the Lab Requisition Form, click here.
Use a Black or Blue ballpoint pen, write or print legibly and firmly. Each requisition must have the following information:
-
Patient Sample Information
-
Complete first and last name
-
Social Security number (SS#) is a must if patient has Medicare or Medicaid; medical record number (MR#), or other patient identification number, if available.
-
Collection date and time
-
Specimen collection details – FNA washout, serum, or plasma
-
Address and phone number of patient (if available)
-
DOB (date of birth)
-
Sex
-
Test request(s)
-
ICD-10 Code (Diagnosis code)
Billing Options (one of six) must be clearly marked. For the Insurance option, front and back copies of all insurance cards/information should be provided. Alternatively, information should be printed legibly on the requisition including name of the insurance company, an address, phone number and group number.
Referring Physician’s name, NPI number, and phone number.
In order to ensure positive identification and preserve maximum integrity of patient samples from the time of collection until testing and reporting have been completed, specimens should be labeled with the patient’s first and last name, and a unique identifying number. The name or ID number on the requisition must match the name or ID number on the specimen(s). Any labelling discrepancy will cause delay and may lead to cancellation of the request. Clients will be notified of inappropriately labeled specimens.
Unlabeled specimens will not be accepted.