To request printed test requisitions, please contact our client services department at 800-328-2666.
Test Requisition Instructions
Complete all required fields on test requisitions. Ensure that all required fields are filled out and the information submitted is accurate.
Client: Account #, name, department, address, ordering physician, phone #, physician/authorized signature
Patient: Name, gender, DOB, address
Billing: Insurance company name, policy #, group # (attach face sheet and copy of insurance card)
Specimen: Hospital status when sample collected, specimen ID #s, body site, collection date and time
Clinical: ICD-10-CM, clinical indication (attach clinical history and pathology reports), clinical status
Tests/Services: Select tests to be performed
Send a signed, printed copy of the test requisition with your specimens. Please ensure that all information on the test requisition matches the information on the specimens sent (ie, blocks, slides, tubes).
Sample Test Requistions
| Attachment | Size |
|---|---|
 1107, GI EGD Requisition (SAMPLE) | 324.79 KB |
| 1361, Gynecology Requisition (SAMPLE) | 70.99 KB |
| 711, Hematology Oncology Requisition (SAMPLE) | 361.39 KB |
| 1376, Urology Requisition (SAMPLE) | 431.01 KB |
| 260N.26, Urology Requisition (SAMPLE) | 458.62 KB |
| 1192, Ambulatory Surgery Center Requisition (SAMPLE) | 72.05 KB |
| 1190, Dermatopathology Requisition (SAMPLE) | 74.54 KB |
| 1193, Endocrinology Requisition (SAMPLE) | 115.92 KB |
| 1350A, GI Pathology Requisition (SAMPLE) | 63.79 KB |
| 1369, GI Pathology Requisition (SAMPLE) | 101.19 KB |
| 1369C, GI Pathology Requisition (SAMPLE) | 89.26 KB |
| 1121, Lower GI Requisition (SAMPLE) | 71.89 KB |
| 1376T, Urology Requisition (SAMPLE) | 108.78 KB |
| DN 1437, Breast Requisition (SAMPLE) | 71.62 KB |
| 260N.30, Urology Requisition (SAMPLE) | 466.79 KB |
| 261N, Patient Support Services (SAMPLE) | 411.03 KB |