Requisition Requirements

Accurate and complete requisition information is essential to:

  • Assure positive patient identification
  • Improve diagnostic accuracy
  • Compare current findings with prior results
  • Facilitate insurance reimbursement and reduce follow-up calls to your office

⚠️ PLEASE NOTE: ICD-10 diagnosis codes Must be included for each test that is ordered – NO EXCEPTIONS.

  1. Ordering Physician
  • Print the ordering provider’s last name, first name in the top right corner
  1. Patient Demographics

Complete all fields legibly to avoid delays or return calls. Required information:

  • Full Name
  • Mailing Address (include lot or apartment number)
  • Telephone Number
  • Date of Birth (essential for identification)
  • Patient ID (medical record/chart number)
  • Social Security Number (essential for identification)
  • If patient is a minor: Parent/Guardian Name
  1. Insurance Information

Provide primary and secondary insurance details:

  • Insurance Company Name & Address
  • Subscriber Name (exactly as on insurance card)
  • Policy & Group Numbers (include alpha characters) OR attach a copy of the front and back of the insurance card(s)
  1. Collection Date
  • Required for all specimens
  • Critical for Pap Tests: Used to determine menstrual cycle stage and required for HPV testing (must be within 21 days)
  1. GYN Cytology Requests

Include the following:

  • ICD Diagnosis Code(s): Must be included for each test that is ordered – NO EXCEPTIONS
  • Clinical History: LMP, previous testing dates, previous abnormals, and any applicable patient conditions
  • Specimen Source: ThinPrep or Conventional; specify site
  • Age based testing option
  • Reflex HPV DNA Testing: Mark option if applicable. (Do not mark if provider has HPV Reflexive contract.)
  • Additional Testing from ThinPrep: Chlamydia, GC, Herpes Simplex I & II (separate diagnosis codes required)
  1. Non-GYN Requests
  • ICD Diagnosis Code(s)
  • Specimen Source: Type and site (specify right or left)
  • Clinical History: Include relevant conditions, cancer history if known
  1. Surgical Pathology Requests
  • Clinical Diagnosis: Required for correlation with pathology findings
  • Tissue Submitted: List each specimen separately (A, B, C, etc.); include site (right/left)
  • Operation: Specify procedure performed (e.g., hysterectomy, curettage, needle core biopsy)
  1. Signature
  • Sign requisition after completion
  • Signature provides direct contact for follow-up if needed