Laboratory Request Form
To download and print the Laboratory Services Request Form, click here. Instructions on how to properly complete the form are listed below.
The laboratory request form is the first line of communication between the specimen submitting facility, agency, or physician and the laboratory. These forms are available upon request to the laboratory.
Correctly completing this form will insure your patient and specimen are properly identified and matched, the requested procedures are performed in a timely manner, and the results get back to the facility, agency, or physician as requested. All results will be faxed to the ordering facility, agency, or physician only.
The request form includes a place to enter many identifying elements. It has a place for the ordering physician or agency, the patient information, billing information, specimen information, medical necessity justification, and procedures requested.
Information on the form:
| LINE ITEM | INFORMATION NEEDED |
| Physician Information box | List the physician’s office
List the ordering agency (e.g. home health) List the ordering location (e.g. nursing home) |
| Patient Information | Fill in the boxes. Minimum required is:
Patient’s full name Correct Social Security number for the patient Correct Birth date |
| Responsible Party Information | This is completed if some other than the patient will be responsible for financial activities. |
| Billing Information | If the procedure is billed to the patient, please attach a front and back copy of all insurance cards.
If the procedure is billed to a third party, please check the appropriate box. Fill in the correct Medicare / Medicaid number |
| Medical Necessity Information | These include signs and symptoms or the ICD code for the justification of the testing. These can be listed as a narrative diagnosis or the ICD9 code |
| Specimen Information | If the specimen is for culture, the source must be filled in
The time drawn, the date drawn, the “collected by” must be filled in. If the specimen is a 24-hour urine, this must be checked. If the specimen is for monitoring of therapeutic drugs or antibiotics, the time of the last dose must be filled in. |
| Tests requested | The most commonly ordered tests are listed on the form. Other tests may be written in . This area contains a Medicare Approved disclaimer. |
| Tests to be ordered | The tests are listed on the request in groups of panels in bold type. Under each bold type is a listing of the single tests that are within the panel ordered.
All the tests, whether within a panel or not, may be ordered individually. The tests requested may be marked by a check before the test or circled. |
| Specimen type and collection container | Listed on a separate page. Please refer to that page to determine the appropriate specimen to collect and/or the collection container |
Place the specimens into the biohazard bag zipped area.
Place the request form into the biohazard bag area outside the zipped area.
To request the form or if you have questions about how to complete it, please call the laboratory at (423) 837-3452.