Advanced-lab.com

501 Elmwood Ave., Sharon Hill, PA 19079
Phone: (855) 238-4949 · Fax: (855) 238-4946
Requisition Form
Email: info@advanced-lab.com · www.advanced-lab.com
ORDERING PHYSICIAN
SPECIMEN INFORMATION
Physician Signature X
PATIENT INFORMATION
Please Provide Ordering Physician's NPI & Name If Not Listed Above BILLING INFORMATION
ICD-9 DIAGNOSIS CODE(S) For Test Ordered (Must Be Provided) www.cdc.gov/nchs/icd.htm
BILL TO † Doctor † Patient † Insurance † Prepaid
Additional Tests/Custom Profiles/Comments: PAYMENT INFORMATION
† Check † Cash † Money Order † Credit Card CREDIT CARD INFORMATION
† Visa † Mastercard † American Express † Discover I authorize the release of any medical information necessary to process this claim and request payment of benefits to the laboratory. I agree to assume responsibility for payment or charge for laboratory services that are not covered by my health insurance.
Patient's Signature X
Signature X
ORGAN/DISEASE PANELS
MICROBIOLOGY
HEMATOLOGY/COAG
PREGNANCY EVALUATION
LIPIDS/CHD RISK/CARD. EVAL
THERAPEUTIC DRUGS
TUMOR MARKER
Fungal Direct Examination (KOH) STR.
CHLAMYDIA/GC USING rRNA
BLOOD TYPE
IRON/ANEMIA/MALNUTRITION
DIABETES EVALUATION
STOOL CULTURE/PATHOGENS
SEROLOGY/INFECTIOUS DIS.
GENERAL CHEMISTRY
ENDOCRINE
OTHER TESTS
PANEL LISTING (Panels on the Front of this Requisition) All laboratory procedures will be billed to the third party carriers as fees billed to patient, and in accordance with the specific CPT coding required by the carrier. Test components of panels are listed below and may be ordered individually. Components may be billed separately per carrier policy. All reflex testing will be done at an additional charge e.g., if ANA is positive a titer will be performed. If beta-Strep culture throat culture is positive, serological grouping will be performed. IF RPR test is reactive, a titer and confirmatory test [FTA] will be performed. If HBsAg is positive, it will be confirmed by neutralization. If HAV Ab total is positive, HAV IgM Ab will be performed. If HSV is positive, confirmation and typing will be performed. If urinalysis indicates a need, a urine culture will be performed. If Microbiology culture is positive, additional procedures such as susceptibility testing, Identification, serotyping etc. will be performed [based on CLSI standards] and billed in addition to the primary codes. For CBC, if abnormal cells are noted on a manual review of peripheral blood smear or if the automated differential indicates a possible discrepancy, a full manual differential will be performed. The manual differential will replace the automated one at an additional charge.
Amenorrhea Panel
Basic Metabolic Panel
Diarrhea Panel
Lipid + Panel
Electrolyte Panel
Anemia Panel
CBC w Diff
Arthritis Panel
Obstetric Panel
Hepatic Function Panel
CBC w/o Diff
Autoimmune Disorder Panel
Renal Funct
Comprehensive Metabolic Panel
Hepatitis Panel, Acute
Iron and IBC
Thyroid Panel
B12 and Folate
Lipid Panel w/ LDL/HDL Ratio
Shipping Instructions:
Specimen Code: [S] Red/Gray Spun SST, [US] Red/Gray Unspun SST, [R] Red, [L] Lavender, [B] Blue, [G] Gray, [GN] Green, [RB] Royal
Blue, [Y] Yellow, [SER] Serum Transport, [PLS] Plasma Transport, [FZ] Frozen Transport, [U] Urine Tube, [TU] Timed Urine, [F] Fluid, [SW]
Culture Swab, [P] GC/Chl. Swab, [STR] Sterile Container, [SAL] Saline Transport, [O&P] O&P Kit, [V] Viral Transport

Source: http://www.advanced-lab.com/downloads/GenericReqForm.pdf