What information is required on a test requisition form?

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The following are the directions on how to fill out a Laboratory Alliance test requisition for testing that originates in the physician office setting:

1. Specimen Information

Include Date and Time Collected and initials of the person who collected the specimen.
COPY TO: Indicate full physician name (e.g.: Dr. Joe Smith) if an additional copy needs to be sent to another physician.
Physician signature is REQUIRED in this section for Medicaid patients only.

2. Patient Information

Fill in patient’s Name and Date of Birth (DOB)
All other information should be filled in completely or attach a billing face sheet to the requisition.

3. Insurance Billing Information

Fill in completely or attach a billing face sheet to the requisition.

4. ICD-10/Dx Code

Fill in the boxes with the appropriate (e.g. medically necessary) diagnosis codes for the tests that have been ordered.
Please refer to this page on our website for NCD/LCD listings of acceptable medical necessity diagnosis codes.

5. Patient Authorization

Make sure that the patient signs the authorization.

6. Test Orders

Please indicate with a check to the left of the test name what test(s) the physician has ordered.

7. Advance Beneficiary Notice (ABN)

The ABN is a separate form that can be obtained from Laboratory Alliance by submitting a Supply Order Request. The ABN only needs to be signed by the patient if the physician feels that the diagnosis code may not be appropriate (not medically necessary) for the test ordered. Please refer to the NCD and LCD websites for coverage determinations:

For LCD information: www.umid.nycpic.com/lcd.html

For NCD information: http://www.cms.hhs.gov/coveragegeninfo/downloads/manual4/pdf

Please fill in the patient’s name and Identification Number (Medicare #).
In the section “Lab Test(s),” please indicate with a check mark the test(s) that you feel that Medicare may not pay for due to the condition of the patient, if it is a frequency limited test, or if the test is for experimental or research only. If a test is not listed and you feel it might fall into one of the above categories, please write the name of the test under one of the blank lines on the form.
In the section "Reason May Not Pay", check appropriate reason.
Under “Estimated Cost“, you must provide the patient with an estimated cost of the test(s).
Under “Additional Information”, any additional clarification for the beneficiary may be entered.
Under "Options", please have the patient select an option.
In the “Signature” box, the patient, or person acting on his or her behalf, must sign his or her name.
In the “Date” box, the patient, or person acting on his or her behalf, enters the date on which he or she signed the ABN.

Important Note: All of the sections of the ABN need to be filled in; otherwise the ABN will not be acceptable by Medicare.

No Appointment Necessary 11 Patient Service Centers in Central New York.

A test requisition form (General Test Requisition Form, OBGYN Test Requisition Form or Urology Test Requisition Form) must be submitted for each patient and completed based upon the instructions below.

Instructions for Completing a Test Requisition Form

A test requisition form must be submitted for each patient. If multiple specimens are submitted on one patient which require separate transportation conditions, please use separate biohazard bags and forms.

The following sample test requisition form has been numbered 1 to 5 as a reference for each of the 5 steps below.

Please complete all of the following information in this section. Not only is it important for positive patient identification, but also for billing purposes.
- Patient Name
- Sex
- Mailing Address
- Social Security Number
- Date of Birth
- Daytime Phone Number
All ordering physicians must provide complete information, including the NPI # and/or UPIN #, the first time a specimen is submitted. Once that physician is added to our database, the physician’s name, office location and MDL Account # are sufficient.
One billing option must be checked. If no information is provided, the patient will be billed directly. If submitting third party information, either complete all areas or simply attach a photocopy of the front and back of the patients insurance card. Be sure to include appropriate diagnosis codes when submitting specimens for third party billing patients.
The date of collection is a very important, often overlooked piece of information. If the actual transport time exceeds the recommended time frame, then the integrity of the results may be compromised. It is also essential in determining the order of specimens in serial testing. Please identify the source of any specimen other than blood. This is particularly important for biopsies and body fluids.
Don’t forget to indicate all tests being ordered on the Test Requisition!

What is a test requisition form?

A test requisition form is used by healthcare professionals to request laboratory tests such as urine or blood testing. Test requisition forms are often called lab forms. When blood, urine, or tissue is sent to a lab from a doctor’s office a test requisition form is required. The patient demographics, ordering physician, insurance information and what test should be performed will be on this form.

Test requisition forms normally include barcode labels along with readable numbers. The barcode labels are used to identify corresponding containers with sample to be tested.

Are there different types of test requisition forms (lab forms)

There are several different types and variations of test requisition forms (lab forms): There are digital laser printed single or multipart NCR forms, hand written multi-part NCR forms, and computer printed multi-part pin-fed NCR forms.

What is a lab requisition form?

A lab requisition form is used by healthcare professionals to request laboratory tests such as urine or blood testing. They are also called test requisition forms. When blood, urine, or tissue is sent to a lab from a doctor’s office a lab requisition form is required. The patient demographics, ordering physician, insurance information and what test should be performed will be on this form.

Lab forms normally include barcode labels along with readable numbers. The barcode labels are used to identify corresponding containers with sample to be tested.

How does a lab form barcode label work?

A barcode label works as follows:

A scanner on a computer shines LED or laser light on to barcode.
Light reflects back off the barcode into a light-detecting component in the computer allowing the computer to read the information.
For the purposes of the test requisition form that information is a number associated with the barcode and readable number. This is so lab will know who the samples belong to and where to send the results.
Without this barcode, there wouldn’t be a way to keep the samples and test forms together. So, for example if a patient John Smith had blood draw for drug testing for a job and so did Maria Smith the lab will have a way of tracking each specimen so that Johns’ results get to his future employer.

Are there different types of barcode labels on test requisitions forms?

There are two types of test requisition forms: piggy back labels; and integrated bar code labels. If your requisition form is going to be printed on a laser printer or handwritten the best way is integrated barcode labels. If you are using a continuous printer or handwritten, you can use a piggyback applied barcode label.

What is a lab form with integrated barcode label?

Integrated barcode labels take on many variations, however, a basic definition would be the application of a label liner material to the back of a sheet. The face is then die cut to allow for the removal of a label. The liner can have a NCR coating to allow you the ability to write on the label and go through to second sheet.

Custom label sizes are available on lab forms. There are many standard size labels to choose from to avoid extra die charges.

What is a piggyback applied barcode label?

A piggyback barcode label is constructed of two labels, one label sits on top of the other label but slightly smaller (this is where the word piggybacks comes from). These labels have five layers: a face material, an adhesive layer, a release liner, another adhesive layer, and a backing sheet.

Piggyback barcode labels work well with continuous printed or handwritten test requisition forms. However, they do not work at all with digital printed (laser printed) forms. The heat from the laser printer melts the adhesive and will jam up your machine.

How many barcode labels can be placed on a test requisition form?

The number of barcode labels included on a test requisition form depends on what is determined by what tests will be run per form. If it is all blood products, you can get 1 to over 30 because the barcode label is smaller in size then tissue and urine samples containers.

You should consult with a professional printing company that specializes in barcode label test requisition forms.

Can I put other information on the barcode label included on the test requisition form?

Addition information can be added to barcode labels on test requisition forms. Most often the patient’s name and date of birth are included. This information is a second verification for the lab doing the testing.

We Design Custom Test Requisition Forms
(commonly referred to as Lab Forms)

Barcode Label and Test Requisitions forms on-demand delivery.

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