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Laboratory Instructions for Completion of Routine Request Forms

Client Name

  • Enter name and complete address of client (if not preprinted).
  • Enter phone and fax numbers for handling of results.

Requesting Physician Signature

  • Enter first and last name.
  • Enter phone and fax numbers for handling of results.
  • Patient Information
  • Please print clearly, using a pen. Do not use “cursive or script” handwriting when filling out the form.
  • Enter patient last name, suffix (Jr., Sr., III), first name, middle initial.
  • Mark sex—M or F—many tests are sex-related.
  • Enter birthdate and social security number for patient identification.
  • Enter complete current patient address, including apartment numbers, lot numbers, P.O. box numbers, and zip code for registration and billing.

Billing

Enter X in the appropriate box:

  • If client is to be billed, (X) Doctor/Client
  • If patient is to be billed, (X) Patient
  • If insurance is to be billed, (X) insurance and complete the following sections: Insured name, relationship to patient (if not patient), responsible party (first and last name); insurance company name including Medicare or Medicaid; certificate or identification number, group number/name. A copy of both sides of the insurance card must be attached to the request.
  • If Medicaid is to be billed, (X) Medicaid and complete the Primary Insurance section with the Medicaid number.
  • If Medicare is to be billed, (X) Medicare and complete the Primary Insurance section with the Medicare number.
  • If Medicare Replacement is to be billed, (X) Medicare Replacement and complete the Primary Insurance section with the Medicare number.

Diagnosis Code (ICD-10)

  • Enter all ICD-10 diagnosis codes for each test requested.

General Instructions

  • Read and follow instructions for completing the Advanced Beneficiary Notice (ABN) on reverse side of request form if appropriate.

Tests to Order

Mark (X) in box preceding test(s) desired and collect specimen required as indicated in “Alphabetical Test Listing” section of the Saint Luke’s Regional Laboratories (SLRL) Service Directory or by the letter code to right of test name on request form. Collection code legend is at bottom of form.

Tests have been divided into the following sections:

  • Organ or Disease Oriented Panels: Read specific information and follow instructions under this section.
  • Disease Strategy Cascades: Read specific information.
  • Other Panels: Component tests in these panels are listed on the back of request with corresponding CPT code.
  • Microbiology Studies: Refer to SLRL Service Directory for specimen requirements, collection, and storage temperatures. Write those not listed in space labeled “Additional Tests.” All microbiology specimens must have source indicated.
  • Individual Tests: Listed in alphabetical order; those not listed may be entered in space labeled “Additional Tests.”
  • Urine Studies: Refer to SLRL Service Directory for specimen requirements and preservative for 24-hour collections.
  • Toxicology: Refer to SLRL Service Directory for specimen collection, special requirements, and paperwork.

Specimen Information

  • Enter date and 24-hour clock time for specimen collected, if done by client.
  • Enter initials of phlebotomist in “Collected By” box.
  • Complete tube tally with number of tubes collected by color indicated (see code legend).
  • Mark (X) in “STAT” box if appropriate.
  • Complete “Results” area with phone or fax number for STATs if desired.
  • Retain the yellow copy of the request for your records