Fillable Test Requisition Form

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Test Requisition Form

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SPECIMEN COLLECTION
TIME __________
AM
PM DATE_________
General Test Requision Paent Informaon
ACCT: Last Name First Name MI
Male
Female D.O.B. / /
Address (Street) Apt # Floor Room #
City State Zip Telephone #
Call results to: ( )
Fax results to: ( )
Responsible Party/Subscriber Social Security # Client Chart/Pt. ID#
Billing informaon*
Bill Paent
Bill Client
Bill Medicare
Bill Medicaid
Bill Insurance
SELF
SPOUSE
CHILD
OTHER
Medicare# (Include Prex/Suix) Medicaid # State
Insurance Company Name Telephone #
ICD 9 DIAGNOSIS CODE(S) FOR TESTS ORDERED
Subscriber Member # Locaon Group #
MEDICARE ADVANCE BENEFICIARY NOTICE (ABN)
Signature____________________Date__________
DIAGNOSIS/SIGNS SYMPTOM IN ICD-9 FORMATE
Insurance Address Physician Provider
City State Zip
24-HOUR URINE
VOLUME IN ML
FASTING
YES
NO
STAT
A.M.A. PANELS OTHER PANELS
10 ELECTROLYTES SS
Na, K, Cl, CO
2
11
BASIC METABOLIC SS
Na, K, Cl, CO
2
, Glu, BUN, Cr, Ca
12
COMPREHENSIVE METABOLIC SS
Na, K, Cl, Glu, BUN, Cr, CA, TP, Alb, TBil AP, AST, ALT, CO
2
27 HEPATIC FUNCTION SS
Alb, TBill, DBil, AP, AST, ALT, TP
38
LIPID PROFILE SS
Trig, Chol., HDL, LDL calc, VLDL calc, Ratios
29
THYROID1 SST
T4, T3Uptake, FTI, TSH
62
THYROID PROFILE SST
T3p, T4, FTI, T3, FT4, TSH
39
B12 + FOLATE DEFICIENCY SST
GTT2
GLUCOSE TOLERANCE 2 hrs 4GY
24
DIABETIC PROFILE GY, LV
GLU, HGB A1C
31
ARTHRITIS SS, LV
CBC, ANA, ASO, CRP, RF, ESR, URIC ACID
P20 ANEMIA PROFILE SS, LV
CBC, B12, FOLATE, IRON, TIBC, RETIC
2254
ACUTE HEPATITIS PANEL SS
HBSAG, HBSAB, HBcAB, Hav, HCV
P123
PSA FREE & TOTAL SS
983 PLAC Black/Yellow
Y19
NMR Black/Yellow
1901 East Linden Ave
Suite 4, Linden, NJ 07036
Tel.: 908-474-1004 • Fax: 908-474-0032
2269 THIN PREP 1336 THIN PREP, w/REFLEX HPV HI 2280 THIN PREP, w/HPV HIGH RISK CYTOLOGY CX VG LMP _______/_______/__________
ACCU
REFERENCE MEDICAL LABS
CUSTOM PROFILES/ADDITIONAL TESTS:
LAB USE ONLY
61 ABO GROUP & RH LV/RE
Q099
AFP Maternal Quad Screen SS
197
AFP Tumor marker SS
101
ALBUMIN SS
102
ALK. PHOSPHATASE SS
106
ALT (SGPT) SS
105
AMYLASE SS
0301
ANA Screen/IFA SS
302S
ASO (Quant) SS
107
AST (SGOT) SS
129
BILIRUBIN, Total SS
113
BILIRUBIN, Direct SS
S204
BNP-NT-pro SS
136
BUN SS
684
CA 125 SS
696
CA 15.3 SS
A042
CA 19.9 SS
A063
CA 27.29 SS
103
CALCIUM SS
20
CBC, DIFF, PLT LV
383
CEA SS
135
CHLORIDE SS
110
CPK SS
112
CREATININE SS
1536
CRP QUANT SS
2007
CARDIO SS
Q190
Cystic Fibrosis, 32 mut LV
148
DIGOXIN RE
151
DILANTIN RE
A043
DNA DS, IGG IFA SS
1120
5 PANEL DRUG SCREEN UA
T267
EBV EVALUATION SS
1210
ENA (Smith), Ab IGG SS
185
ESTRADIOL SS
115
FERRITIN SS
S892
FIBRINOGEN BL
163
FOLATE SS
139
FSH SS
116
GGT (GGTP) SS
117
GLUCOSE fasting GY
179
GLUCOSE PP 1h GY
119
GLYCO Hgh A1c LV
GLYCOMARK SS
147
HCG Beta sub SS
A232
Hep A Total Ab SS
319
Hep B Surface Ag SS
320
Hep B surf Ab SS
321
Hep B core Ab SS
318
Hep B core IgM SS
A701
Hep C Ab SS
108
HDL Cholesterol SS
HERP
HERPES IgG I & II SS
S747
HEMOGLOBIN ELECTROPH. LV
303
HETEROPHILE Scr (MONO) SS
0980
HIV-1/2 AB SS
HPYG
H.PYLORI Ab IgG SS
7110
H.PYLORI Ab IgM SS
677
HOMOCYSTEINE SS
S806
LEAD LV
123
LDH SS
1877
LDH Direct SS
140
LH SS
3369
LIPASE SS
S157
LIPOPROTEIN-A SS
S090
LITHIUM (Serum or pl) SS
LYME
LYME Ab IgG/IgM Ref West Blot SS
125
MAGNESIUM SS
944
MEASLES Ab IgG (Rubeola) SS
12
MICROALBUMIN UA
765
MUMPS Ab IgG SS
787
PARATHYROID Horm. Intact. LV/SS
150
PHENOBARBITAL RE
127
PHOSPHORUS SS
134
POTASSIUM SS
A134
PROGESTERONE SS
181
PROLACTIN SS
131
PROTEIN Total SS
PROS
PROT. ELECT. PH./SPEP SST
142
PROSTATIC ACID PHOS. SS
S123
PSA FREE SS
196
PSA SS
036
PT/INR BL
037
PTT BL
247
RETICULOCYTE cnt LV
304
RF (Rheumatoid) SS
311
RUBELLA IgG Ab SS
305
RPR SS
246
SED RATE (ESR) LV
056
SICKLE Cell Monitoring LV
133
SODIUM SS
252
T4, FREE SS
145
T3, UPTAKE SS
980
T3, Total SS
144
T4, Total SS
A623
TEGRETOL (Carbam) RE
187
Testosterone, Total SS
T315
Testosterone, Free & Total SS
156
THEOPHYLLINE RE
IRIB
IRON/TIBC SS
132
TRIGLYCERIDES SS
146
TSH SS
137
URIC ACID SS
030
URINALYSIS UA
962A
VALPROIC ACID DEPAKENE RE
VAP
VAP SS
S402
VARICELLA Ab IGG SS
162
VITAMIN B1 SS
995
VITAMIN D-25 HYDROXY SS
CULC
CULT. FLUID FL
534
CULT. GENITAL SW
602B
CULTURE, STOOL ST
604
CULT.THROAT (Strep A, B) SW
S031
URINE CULTURE UC
69
URINE CULTURE w/sens. UC
606
CULT WOUND SW
S100
O & P STOOL ST
5620
GC & CHLAMYDIA SW/UA
Q472
C. DIFF.TOX. EVAL (A,B) ST
770
OCCULT BLOOD ST
S128
VAGINAL PATHOGENS DNA DI. BD/Affirn
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Test Requisition Form

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Completed 18 July 2020

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