Lab Requisition Form

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Centegra Clinical Laboratories
Date of Service: _________________
Ordering Physician: Please Print _ ___________________________________ Signature:_____________________________________________
Office Phone Number:______________________________
Fax Number:_______________________________
Patient Information Required for Testing
First Name
Last Name
MI
DOB
Male
Female
Patient Phone
Indicate Medical Necessity by recording Diagnosis Code that applies next to each ordered test
ICD#
1.
2.
3.
4.
5.
Check one: Bill to office account_______
Bill to Patient/Insurance_______
Must complete ALL information below or attach insurance sheet or copy of front and back of card
Relationship of patient to policy holder:
(circle one)
Primary Ins. Name:
Secondary Ins. Name:
Self
Spouse
Child
Other
Responsible Party:
Address:
Address:
Name:
City,St,Zip
City,St,Zip
Address:
Policy #
Policy #
City,St, Zip:
Group #
Group #
SSN of Guarantor:
Group Name
Group Name
TEST(S) REQUEST: *Complete ABN for Medicare Limited Frequency Tests or Medical Necessity
MICROBIOLOGY
BLOOD TEST
Diagnosis:_____________________
Diagnosis 1:_________________
Diagnosis 3:_________________
Diagnosis 2:_________________
C difficile Toxin(s) (87324)
Genital Culture (87070)
ABO/Rh (86900 & 86901)
* Digoxin (80162)
Phenobarbital (80184)
Group B Strep Culture (Vaginal) (87081)
Group B Strep, Culture (Vaginal) (87081)
Antibody Screen (Blood Type) (86850)
Antibody Screen (Blood Type) (86850)
Dilantin (80185)
Dilantin (80185)
Phosphorus (84100)
Phosphorus (84100)
Ova & Parasites (87177)
Albumin (82040)
* Ferritin (82728)
Potassium (84132)
Occult Blood, stool (82272)
ALK Phos (84075)
FSH (83001)
Progesterone (84144)
Fecal Occult Blood Screen
(82270
-
)-G0328
ALT (SGPT) (84460)
* Glucose (82947):
Prolactin (84146)
Rapid Strep Group A, Throat (87430)
Amylase (82150)
Fasting___ Non Fasting___
Protein, Serum (84155)
Stool Culture (87045)
ANA (86038)
* Glycohemoglobin
PSA Diagnostic (84153):_________
Throat Culture (87081)
PSA Medicare Screen
AST (SGOT) (84450)
(HgA1C) (83036)
-G0103 (V7644)
* Urine Culture (87086)
Bilirubin Total (82247)
HCG, Qual Serum (84703)
PSA Screen (V7644) (84153)
Collection Method:____________
Bilirubin Direct (82248)
HCG, Quant Serum (84702)
* PT (Protime) (85610)
Wound Culture (87070):
* BNP (83880)
HCG, Quant Tumor Marker
Anticoag: _____________________
Source:________________
BUN (84520)
Hepatitis B surface antigen
* PTT (Partial Thromboplastin) (85730)
Sputum Culture (87070)
Calcium (82310)
* HIV (86703)
Reticulocyte Count (85045)
Other:_________________
CBC w/diff (85025)
* Iron (83540)
RF (86430)
URINE TESTING
* Iron & TIBC (
)
* CBC no diff (Hemogram) (85027)
Rubella Antibody (86762)
83550 & 83540
Diagnosis:_____________________
* CEA (82378)
(includes % Saturation)
* Sed Rate (ESR) (85651)
Urinanalysis w/ Reflex Culture
Chloride (82435)
LDH (83615)
Sodium (84295)
Urinalysis (81003)
* Cholesterol (82465)
Lead, Whole Blood (83655)
Tegretol (80156)
Creatinine Clearance, 24 hr (82575)
* CK (CPK) (82550)
Lipase (83690)
Theophylline (80198)
Height:___________
Creatinine (82565)
Lithium (80178)
* Triglyceride (84478)
Weight:__________
CRP, Inflammation (86140)
* Magnesium (83735)
Uric Acid (84550)
Microalbumin, Random (82043)
* CRP, Cardiac (86141)
Mono Test (86308)
Valproic Acid (80164)
CHEMISTRY PROFILE
Total Protein, 24 hr (84156)
Diagnosis:_____________
Other:_________________
*THYROID TESTING
Electrolyte Panel (80051):
Liver (Hepatic) Panel (80076): (Alb, Total Bil, Dir Bil,
Diagnosis:__________________
(Na, K, C1, CO2)
Alk Phos, AST, Alt, Prot)
*TSH w/reflex to Free 4 (84443)
Basic Metabolic Panel (80048):
* Lipid Panel (80061): (Chol, Trig, HDL)
*TSH (84443)
(Na, K, C1, CO2, BUN, Cre, Glu, Ca)
Renal (Kidney) Functional Panel (80069): (Na, K, C1,
*Total T3 (84480)
Comprehensive Metabolic Panel (80053):
CO2, BUN, Cre, Glu, Phos, Alb, Ca)
*Free T3 (84481)
(Na, K, C1, CO2, BUN, Cre, Glu, Ca,
* Hepatitis Panel, Acute (80074): (Hep A, Ab, IgM,
*Free T4 (84439)
Alb, Tbil, Alk Phos, Protein, AST, ALT)
Hep C Ab, Hep B Surf Ag, Hep B Core IGM)
ADDITIONAL TESTS
Diagnosis:___________________
13704031CL 07-12, 09-12

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