Lab Requisition Form PDF Details

When a physician determines that a patient needs to undergo laboratory tests to diagnose or monitor a condition, a Lab Requisition form serves as the bridge connecting the healthcare provider's request and the laboratory's execution of these tests. This crucial document, filled out with meticulous attention to detail, specifies the patient's vital information, including name, date of birth, and sex, alongside the requesting physician's details such as name, address, phone number, and fax number. It also outlines the tests required, labeled under various categories like Urinalysis, Hematology, Coagulation, Chemistry Profiles, and more, each with specific tests enumerated for clarity. Special sections are devoted to Therapeutic Drug Monitoring and Special Chemistry, indicating the broad range of potential examinations for assessing patient health. Notably, the form underscores the necessity of including ICD 9 DIAGNOSIS CODE(s), reminding healthcare providers of Medicare's limitations regarding routine screening tests. Additionally, instructions regarding fasting, urgency of the tests (STAT, ASAP), and even special conditions like pregnancy testing or 24-hour urine tests highlight the form's comprehensive nature. The directive for specifying the time of the last dose for therapeutic drugs underlines the precision required in testing for accurate results. Furthermore, provisions for peak and trough measurements in Therapeutic Drug Monitoring reflect the attention to detail necessary for managing patient medication levels effectively. This form, serving both as an order for the lab and a record for the provider, ensures that all involved parties have the information needed to proceed with testing, thus playing a pivotal role in the patient's care continuum.

QuestionAnswer
Form NameLab Requisition Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesblank lab sheet template, quest requisition form, permanente laboratory requisition form, signature healthcare lab requisition form

Form Preview Example

Community Physician

LABORATORY REQUISITION

 

 

UPIN / NPI#_____________________

Provider Name:

_______________________________________________

______________________________________________

ADDRESS:__________________________________________

PHONE NUMBER:____________________________________

SECURE FAX NUMBER:_______________________________

**Required**

ICD 9 DIAGNOSIS CODE(s):

**Medicare does not generally cover routine screening tests.

FILL IN ALL INFORMATION

MALE

 

FEMALE

DATE OF BIRTH:______________________

 

 

PATIENT NAME: LAST,

FIRST

_____________________________________________________________________

(KAISER MEDICAL RECORD #____________________________________________

NON- FASTING

STAT

ASAP

FASTING HOURS _____ ROUTINE

Providers FAX this signed and dated form to: 303-404-4030

 

URINALYSIS

 

 

81003

UA reflex MICRO if positive- 81002

 

87088 URNC/CULTURE (reflexed as indicated)

HEMATOLOGY

85025 CBC/AUTO DIFF(man diff reflexed if meets criteria)

85652 ESR - SED RATE

85014/85018 Hemoglobin & Hematocrit

 

85046

RETICULOCYTE

 

 

 

COAGULATION LB/SP1 L

 

 

 

85610

PT

PROTIME / INR

 

 

 

85730

PTT

APTT

 

 

 

CHEMISTRY PROFILES

 

 

 

80048 BMP

Chem 7 (LYTES,BUN,CREAT,GLU,CA)

 

 

80053

CMP Comp Metatobolic Prof (BMP,HFP,TP)

 

 

80061 FLIPP

FASTING (CHOL,TGL,HDL,LDL)

 

 

 

83550 / 83540 IRPF Iron Panel (FE,IBC,TIBC,TRANS SAT)

 

 

80076

HFP

Hepatic Function Panel

 

 

 

 

 

(ALB,AST,ALT,ALKP,TBIL/DBIL)

 

 

80051

LYTES ( NA,K,CL,CO2)

 

 

 

80069 RFP

(LYTES,BUN,CR,GLU,CA,ALB,PHOS)

 

 

84443

THYP

FT4

reflexed if TSH abnormal

 

 

 

 

 

FT3 reflexed if TSH low and FT4 norm

 

 

CHEMISTRY SINGLE TESTS

 

 

 

84460

ALT

(SGPT)

 

 

 

82150

AMYLASE

 

 

 

 

84450

AST

(SGOT)

 

 

 

82247 BILIRUBIN, TOTAL- ADULT

 

 

 

84520

BUN

 

 

 

 

 

82310

CALCIUM

 

 

 

 

82550

CPK

 

 

 

 

 

82565

CREATININE

 

 

 

82728

FERRITIN

 

 

 

 

82746

FOLATE

 

R

 

 

82947 GLUCOSE, ___HRS PP

 

 

 

83036

HEMOGLOBIN A1C

LAV

 

 

84132

POTASSIUM

 

 

 

83690

LIPASE

 

 

 

 

83735

MAGNESIUM

 

 

 

 

84100

PHOSPHORUS

 

 

 

83970/82310/82565/84100

 

 

 

PTHINT INTACT PTH-Fasting preferred

SST & LAV

 

82043 / 82570 RMA

RAND URINE PROT/CREAT RATIO

 

84295

SODIUM

 

 

 

 

 

84443

TSH

 

 

 

 

 

84550

URIC ACID

 

 

 

 

82607

VITAMIN B12

 

 

 

 

82746/82607 VITAMIN B12/FOLATE

 

 

 

THERAPEUTIC DRUGS

 

 

 

DATE AND TIME OF LAST DOSE:

 

 

 

 

 

 

 

 

 

80162

DIGOXIN

 

 

 

 

80185

DILANTIN

 

R

 

80170

GENTAMYCIN

 

 

 

 

 

 

PEAK

TROUGH

 

80178

LITHIUM

 

 

 

 

 

80156

TEGRETOL (CARBAMAZEPINE)

 

80164 VALPROIC ACID (DEPAKOTE)

 

80202

VANCOMYCIN

 

 

 

 

 

 

PEAK

TROUGH

 

SPECIAL CHEMISTRY

 

 

 

86592

RPR

SYPHLIS SCREEN

 

 

 

84165

SPEP

SERUM PROT ELECTROPHORESIS

 

86706 HEPATITIS B SURFACE AB

 

 

 

OTHER TESTING

 

 

 

GLUCOSE TOLERANCE (OB)

 

 

 

 

82950

 

1 HOUR

 

 

 

 

82947 (X2)

2 HOUR POST MEAL

 

 

82947 (X4)

3 HOUR TOLERANCE

 

84703

SERUM PREG

 

 

 

81025

URINE PREG

 

 

 

84702

BETA HCG QUANT

 

 

 

82670

ESTRADIAL

 

 

 

84144

PROGESTERONE

 

 

83001 (+ 83002) LH/FSH

 

 

 

 

 

 

24 HOUR URINE TESTS

 

 

82575 CRCL

CREAT CLEARANCE W/ SERUM

 

 

82340

UCA

CALCIUM

 

 

84166

UPEP

URINE PROTEIN ELECTROPHORESIS

 

 

84156

UPROT TOTAL URINE PROTEIN

 

24 hour urine containers can be picked up at any Kaiser Permanente laboratory location.

No appointments necessary for routine laboratory testing at any Kaiser Permanente lab facility

No specimens will be accepted at any Kaiser Permanente facility

To Order Any Other Test,

Provider must call: 303-743-5330

The tests on this requisition have been approved by the attending physician.

Provider signature

Date

DRAW SITE _________# OF STICKS _________

UNABLE TO DRAW _________

Physician notified?

YES

NO

SST__________ LAVENDER_________ RED_________

BLUE_________ GREEN_________ GRAY_________ URINE_________ STOOL_________SWAB__________

For questions regarding tube types or other specimen collection issues, call the Laboratory Client Services Dept. at

303-404-4050 M-F 8am-6pm

COMMENTS:

 

LABORATORY LOCATION

RECEIVED BY:

 

Reorder form # 00254730 Kaiser Permanente form updated on 6/07

 

 

 

 

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In an effort to fill out this PDF document, make sure you enter the required details in every single field:

1. When filling in the quest requisition form, make sure to include all of the essential blanks within its relevant form section. This will help speed up the process, allowing your information to be handled without delay and accurately.

Filling in part 1 in permanente laboratory requisition form

2. The next part is to fill out the following fields: COAGULATION LBSP L, PTT APTT CHEMISTRY PROFILES, UA reflex MICRO if positive, R LAV, FT reflexed if TSH low and FT norm, CHEMISTRY SINGLE TESTS, ALBASTALTALKPTBILDBIL, SGOT, SGPT, THERAPEUTIC DRUGS, MAGNESIUM PHOSPHORUS PTHINT, SYPHLIS SCREEN SERUM PROT, SPECIAL CHEMISTRY, PEAK TROUGH, and PEAK TROUGH.

UA reflex MICRO if positive, R LAV, and PTT APTT CHEMISTRY PROFILES inside permanente laboratory requisition form

3. This next step is related to UA reflex MICRO if positive, R LAV, HOUR, GLUCOSE TOLERANCE X HOUR POST, SERUM PREG URINE PREG BETA HCG, LHFSH, attending physician, Provider signature, Date, DRAW SITE OF STICKS, For questions regarding tube types, SST LAVENDER RED BLUE GREEN GRAY, UNABLE TO DRAW, LABORATORY LOCATION, and Physician notified - type in every one of these blanks.

Stage # 3 for submitting permanente laboratory requisition form

Be extremely attentive when filling in DRAW SITE OF STICKS and HOUR, as this is where many people make mistakes.

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