The information required on requisitions is essential to assure positive patient identification, improve diagnostic accuracy, compare clinical information, and to compare current findings with other test results.
1. Ordering Physician: Enter the ordering provider’s name (last, first) on the top right side.
2. Patient Demographics: In order to be reimbursed for our services it is crucial that legible patient demographic information be provided. Incomplete or illegible information may result in phone calls to your office. To minimize the disruption to your office staff, please complete the following fields:
- Full Name
- Mailing Address (include lot or apartment number)
- Telephone Number
- Date of Birth (essential for patient identification)
- Patient ID (medical record number or chart number)
- Social Security Number (essential for patient identification)
- If a minor child, list name of parent/guardian
3. Insurance: Please provide primary and secondary insurance information.
- Name and address of insurance company
- Subscriber Name as it appears on the insurance card
- Policy number and group number including alpha characters
- Or simply attach copy of front and back of insurance card(s)
4. Collection Date: This is especially important on Pap Tests, as it is used with clinical history to determine where the patient is in her menstrual cycle, and is required when ordering HPV testing as they must be performed within a twenty-one day window.
5. GYN Cytology Request
- ICD Diagnosis Code: Please indicate if Routine Screen. If it is a Diagnostic Pap, please include the correct diagnosis code.
- Specimen Source: Indicate whether ThinPrep or Conventional and specimen source. If ThinPrep Pap is chosen indicate which Reflex HPV DNA option is to be performed on the residual specimen. Note: No HPV testing should be marked if provider has an HPV Reflexive contract.
- Additional Testing from ThinPrep: Select from the following tests: Chlamydia, GC, and Herpes Simplex I & II. Separate diagnosis codes are required for these additional tests.
- Clinical History: LMP (Last menstrual period) is required for proper evaluation of the Pap test. Also indicate other conditions listed that apply to the patient.
6. Non-GYN Request
- Specimen Source: Indicate type of specimen and whether right or left if applicable.
- Clinical History: Check all appropriate conditions that apply, including cancer history if known.
7. Surgical Pathology Request
- Clinical Diagnosis: This information is required for proper correlation of the clinical diagnosis with the pathologic diagnosis.
- Tissue Submitted: List all specimens separately which are submitted in each container to include specific site, (i.e. right, left).
- Operation: Specific procedure performed to obtain the specimen(s) (i.e. hysterectomy, curettage, needle core biopsy).
8. Signature: Please sign the requisition form when completed. This provides contact information if follow up is necessary.