download our LAB REQUISITION, click
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, plasma,
blood, or urine.
Address and phone number (if available)
DOB (date of birth)
ICD-9 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,
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 insure 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 or a unique identifying
number. The name or ID number on the requisition must match
name or ID number on the specimen(s). Any labeling
will delay processing of the tests ordered and may lead to cancellation
of the request. Clients will be notified of inappropriately
UNLABELED SPECIMENS WILL NOT BE ACCEPTED.
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