State Of Michigan - Laboratory Test Requisition
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1
2STATE OF MICHIGAN - LABORATORY TEST REQUISITION
Microbiology / Virology
DATE RECEIVED IN LABORATORY
LABORATORY SAMPLE NUMBER
Michigan Department of Health and Human Services - Bureau of Laboratories
P.O. Box 30035 3350 North Martin Luther King Jr. Blvd. Lansing, MI 48909
Laboratory Records: 517-335-8059 Technical Information: 517-335-8067
Fax: 517-335-9871 Web:
SUBMITTER INFORMATION
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AGENCY CODE (If Known)
FP
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TELEPHONE
STD
FAX
CONTACT PERSON/ORDERING PHYSICIAN/PROVIDER NAME
NATIONAL PROVIDER IDENTIFIER #
PATIENT INFORMATION
NAME (LAST, FIRST, MIDDLE INITIAL) or UNIQUE IDENTIFIER
SUBMITTER PATIENT # (If Applicable)
CITY
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ZIP
GENDER
RACE
American Indian or
Black or
Native Hawaiian or other
Other
MALE
FEMALE
Asian
White
Alaska Native
African American
Pacific Islander
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ETHNICITY
ADAP NUMBER
BIRTH DATE (MM-DD-YYYY)
Hispanic or
Not Hispanic or
Unknown
Latino
Latino
COLLECTION TIME (MILITARY)
SUBMITTER SPECIMEN #
COLLECTION DATE (MM-DD-YY)
INDICATE TEST REQUESTED
INSTRUCTIONS FOR COMPLETION: Complete reverse side of form for corresponding numbers in parentheses and in bold.
INDICATE SPECIMEN SOURCE
SEROLOGY
MICROBIOLOGY
TESTS THAT REQUIRE MDHHS APPROVAL
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AMNIOTIC FLUID
SERUM STATUS - If Applicable
AEROBIC ISOLATE ID (5)
EMERGING ARBOVIRUS PANEL
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BRONCHIAL
ACUTE
CONVALESCENT
AFB SLIDE/CULTURE-CLINICAL SPECIMEN
PCR
SEROLOGY
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CERVIX
ARBOVIRUS ENCEP PANEL (IgM)
AFB IDENTIFICATION-ISOLATE ID
AFB NUCLEIC ACID AMPLIFICATION
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CSF
E. COLI (SLT) TOXIN & SEROLOGY
BACTERIAL TYPING-PFGE (6)
May-Oct Includes: Eastern Equine, California,
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GASTRIC
ENTERIC BACTERIAL CULTURE
BOTULISM TOXIN
St. Louis and West Nile
CSF Only
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NASOPHARYNGEAL
BRUCELLA SEROLOGY
FOODBORNE ILLNESS-Stool or Food (6)
MUMPS - PCR
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ORAL MUCOSAL TRANSUDATE
FUNGAL SEROLOGY COMPLEMENT FIX
FUNGAL IDENTIFICATION - ISOLATE ID
MEASLES IgM
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PLASMA
FUNGAL IMMUNODIFFUSION
LEGIONELLA CULTURE
NOROVIRUS PCR (6)
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SERUM
FRANCISELLA SEROLOGY
NEISSERIA GONORRHOEAE - ISOLATION
PERTUSSIS CULTURE
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STOOL
LEGIONELLA - HA
NEISSERIA - REFERRED CULTURE
RUBELLA IgM (1)
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SPUTUM
LYME DISEASE - EIA (4)
PARASITOLOGY - BLOOD
SALMONELLA SEROTYPING NON-HUMAN
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THROAT
MEASLES IgG
PARASITOLOGY - STOOL
TOXIC SHOCK TESTING
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URETHRA
MUMPS IgG
PARASITOLOGY - WORM
OTHER _______________________________
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URINE
RABIES AB SEROLOGY (3)
PERTUSSIS PCR
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OTHER
WHOLE BLOOD
RUBELLA IgG
SALMONELLA SEROTYPING - HUMAN
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FOOD-Specify:
TETANUS TOXIN EIA
SHIGELLA SEROTYPING
AUTOCLAVE TEST STRIPS
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OTHER-Specify:
VARICELLA ZOSTER IgG
LEGIONELLA - DFA
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LYME DISEASE - DFA (Tick)
HIV TESTING
SYPHILIS TESTING
VIROLOGY
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HEPATITIS TESTING
HIV Ag/Ab - Serum (1)
SYPHILIS (USR Test) (1)
ENTEROVIRUS PCR (6)
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HIV Ag/Ab-Oral Mucosal Transudate (1)
SYPHILIS VDRL - CSF Only (1)
RESPIRATORY PCR PANEL
HEPATITIS C ANTIBODY (1)
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CD4/CD8 (EDTA whole blood) (1)
SYPHILIS DFA (1,2)
INFLUENZA (PCR/CULTURE) (7)
HEPATITIS B SURFACE ANTIGEN
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(HBsAg) (1)
HIV-1 VIRAL LOAD (EDTA plasma) (1)
VIRAL CULTURE
SYPHILIS FTA - ABS DS
(1)
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HIV-1 GENOTYPING (EDTA plasma) (1)
HEPATITIS B ANTIBODY (Anti-HBsAg) (1)
SYPHILIS TP-PA
(1)
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HEPATITIS A ANTIBODY (IgM) (1)
SYPHILIS IgM WESTERN BLOT
(1)
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Prior Approval Required
DCH - 0583
May 02, 2016
By Authority of Act 368, P.A. 1978
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