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Test Requisitions

To request printed test requisitions, please contact our client services department at 800-328-2666.

Test Requisition Instructions

Complete all required fields on test requisitions. Ensure that all required fields are filled out and the information submitted is accurate.

Client: Account #, name, department, address, ordering physician, phone #, physician/authorized signature
Patient: Name, gender, DOB, address
Billing: Insurance company name, policy #, group # (attach face sheet and copy of insurance card)
Specimen: Hospital status when sample collected, specimen ID #s, body site, collection date and time
Clinical: ICD-10-CM, clinical indication (attach clinical history and pathology reports), clinical status
Tests/Services: Select tests to be performed

 

Send a signed, printed copy of the test requisition with your specimens. Please ensure that all information on the test requisition matches the information on the specimens sent (ie, blocks, slides, tubes).