laboratory requisition form requirements

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A laboratory test order is required (i.e., paper requisition, electronic medical record, ChildLink TM provider). In the section "Reason May Not Pay", check appropriate reason. Diagnostic Test Menu ; Please include a completed requisition with each patient sample referred to the Diagnostic Laboratories. For use only by authorized healthcare providers Laboratory Services: Lab Forms and Requisitions. Spectrum Health Laboratory will no longer accept patient identifier … State of Illinois CLIA LABORATORY RECORD RETENTION REQUIREMENTS. RIDOH State Health Laboratories Test Requisition . Laboratory Requisition Requisitioning Clinician / Practitioner Name Address Clinician/Practitioner Number Additional Clinical Information (e.g. All other information should be filled in completely or attach a billing face sheet to the requisition. RQHR Lab Specimen Requirements - September 2020 an authenticated medical record . Certification Program (As of 2013 and stated in The Code of Federal Regulations, CFR42 Part 430, Appendix C, Subpart J, §493.1105 Standard: Record Retention requirements) Listed are the CLIA requirements for retaining patient and testing records, specimens and slides. You may print a blank requisition by selecting it below. Laboratory Test Requisition INSTRUCTIONS The Illinois Department of Public Health laboratory requisition form titled, “COVID-19 Laboratory Test Requisition,” is designed to accompany the specimens submitted to the Department’s laboratories by approved submitters for COVID-19 testing. Ethical Considerations 25 36. In the “Date” box, the patient, or person acting on his or her behalf, enters the date on which he or she signed the ABN. Learn about our comprehensive outpatient lab services here. Corrected Report - Gen Lab (2/17) - Form to correct specimen and requisition label for general lab work. Addition information can be added to barcode labels on test requisition forms. Specimen Information. Refer to Patient Instruction Sheet. OAHPP collection of personal health information on this form is collected under the authority of the Personal Health Information Protection Act, s.36 (1)(c)(iii). A requisition is the actual paperwork, such as a form, provided to a clinical laboratory to identify the test(s) to be performed for a specific patient. Are there different types of test requisition forms (lab forms). DEFINITION - Submitter - Entity that sends specimens to be tested. Laboratory … Without this barcode, there wouldn’t be a way to keep the samples and test forms together. What is a lab form with integrated barcode label? Tracking of Acceptance 50 Orms St., Providence, RI 02904-2222 . Post Vasectomy Analysis Requisition (June 2019 Version) Specimen Collection for Fertility Requisition (June 2019 Version) Laboratory Services Manuals. The laboratory test request must provide the following information: Ordering provider's full name, address, phone number, and provider signature Patient’s name and date of birth A scanner on a computer shines LED or laser light on to barcode. New Hampshire Department of Health and Human Services 129 Pleasant Street | Concord, NH | 03301-3852 The barcode labels are used to identify corresponding containers with sample to be tested. Each requisition is numbered with a unique identification number. Forms. COVID-19 Advisory: Visitors limited to only one parent/caregiver at all clinics and no siblings allowed. Requisition Form (Manual or Electronic) 24 32. Please fill in the patient’s name and Identification Number (Medicare #). Add, Add On Test Fax Form - 20721 (Cross: Provincial Laboratory for Public Health (ProvLab) Bacteriology Culture and Serology Requisition - CH-0039 (ProvLab North - Edmonton) Public Health: Bacteriology, Bacteriology Culture and Serology Requisition, CH-0039, ProvLab North: Provincial Laboratory for Public Health (ProvLab) Bacteriology Requisition - 20691 (ProvLab South - Calgary) … Step 3: Request Details The request form should be framed with request information details. Integrated barcode labels take on many variations, however, a basic definition would be the application of a label liner material to the back of a sheet. Under “Additional Information”, any additional clarification for the beneficiary may be entered. The Great Plains Laboratory, Inc., 11813 West 77th Street, Lenexa, KS, 66214, United States (913) 341-8949 customerservice@gpl4u.com The barcode labels are used to identify corresponding containers with sample to be tested. Requisition Forms. Get deals, learn about specials, tips and more. What is a piggyback applied barcode label? However, they do not work at all with digital printed (laser printed) forms. These labels have five layers: a face material, an adhesive layer, a release liner, another adhesive layer, and a backing sheet. In order to meet the unique needs of each provincial healthcare system, please use the form for the province in which you are located. Email 800-245-3117 x 6250 Request Information Online Ordering Portal Forms & Requisitions Sign Up for Versiti Updates. The patient demographics, ordering physician, insurance information and what test should be performed will be on this form. Reporting Test Results 25 35. Page 6 of 43 2020-2021 Laboratory Services Information Manual TEST ORDER ENTRY OUTPATIENTS Laboratory Request Form (Requisition Form) - Physician clients of RCHSD Laboratory are provided with Laboratory Request Forms that contain the physician or practice name and address. Important Note: All of the sections of the ABN need to be filled in; otherwise the ABN will not be acceptable by Medicare. If your requisition form is going to be printed on a laser printer or handwritten the best way is integrated barcode labels. 2008-0253 : Reiterating the Posting of Schedule of Fees for Laboratory and Other Diagnostic Services of Hospitals and Other Regulated Health Facilities as a Mandatory Requirements for Licensing or Accreditation They are also called test requisition forms. There are two types of test requisition forms: piggy back labels; and integrated bar code labels. Select the form that you need: Chain of Custody Request Form Use this form to order tests that could be used in a court of law. (commonly referred to as Lab Forms). 1304 Buckley Road | Syracuse, NY 13212-4302, Copyright © 2021 Laboratory Alliance | Website by SyracuseDesign.com, Customer Service & Other Support Services, Test Requisitions/Consent/Patient History, NYS Department of Health Communicable Disease Phone Numbers, Request for Residual De-Identified Laboratory Specimens, Affiliated Pathologists and Doctoral Level Scientists, Syracuse City School Students Visit the Operations Center, OCM BOCES students visit the Operations Center, P-TECH Ninth Grade Student Presentations at Corporate Office March 2019, Syracuse City School Program Tours Main Laboratory, Laboratory Alliance Employees Serve as Career Coaches, Guidance Counselors Visit Laboratory Alliance, Our Rapid Response Laboratory at St. Joseph's Hospital, Our Rapid Response Laboratory at Crouse Hospital, Congressman Katko Toured Laboratory Alliance in July, http://www.cms.hhs.gov/coveragegeninfo/downloads/manual4/pdf. For more information on test requisition forms, lab forms, integrated bar code or piggyback barcode label forms please contact Unisource Printing Services and Promotions. * Features of the form: Jennifer Rakeman, Ph.D., Assistant Commissioner Instructions for Completing a Test Requisition Form. This information is a second verification for the lab doing the testing. The following are the directions on how to fill out a Laboratory Alliance test requisition for testing that originates in the physician office setting: The ABN is a separate form that can be obtained from Laboratory Alliance by submitting a Supply Order Request. Home » This form can apply to various fields such as purchase requisition forms, equipment requisition forms, and Training Requisition Form. Critical Values Notification Use this form to define contacts for critical values notifications. Skip to nav Skip to content. 401-222-5600; Fax: 401-222-6985; TTY: 800-745-5555. www.health.ri.gov To ensure the timely and accurate processing of all lab samples, it’s important that samples are accompanied by the correct requisition, completed in its entirety. In some cases, such as genetic testing, a consent form may be required. If multiple specimens are submitted on one patient which require separate transportation conditions, please use separate biohazard bags and forms. The information supplied will be included in the laboratory report. Handling Sharps 28 40. medically necessary) diagnosis codes for the tests that have been ordered. Fill in the boxes with the appropriate (e.g. Microbiology Section: Tel 212.447-6783 Fax 212.447-8258 . Learn more. The requisition form should reflect a conscious choice to order the tests, ensuring an independent medically necessary decision for each test the laboratory will bill. Make sure that the patient signs the authorization. You should consult with a professional printing company that specializes in barcode label test requisition forms. These forms generally contain patient demographic and registration information (e.g. It should at least add the name, department and contact details of the party. Lab forms normally include barcode labels along with readable numbers. OTHER TESTING REQUESTS - Please check specimen collection and storage requirements prior to collection Lipase * Indicates tests that may need advanced beneficiary notice (ABN) refer to local and national necessity guide. Canadian Blood Services Requisitions and Forms ordered by Province. Test requisition forms (lab forms) are available in black and white or full color. Contact us for detailed information on various types of test requisition forms – we’d be happy to help. Test requisition forms are often called lab forms. Light reflects back off the barcode into a light-detecting component in the computer allowing the computer to read the information. Part 1 - ISO 9001:2015 “Quality management systems - Requirements” 2. The ABN only needs to be signed by the patient if the physician feels that the diagnosis code may not be appropriate (not medically necessary) for the test ordered. Custom label sizes are available on lab forms. Fire Safety 28 CLUSTER THREE: HEALTH INFORMATION MANAGEMENT 29 41. COVID-19 Specimen Collection Instructions; Chlamydia Trachomatis Culture; Chlamydia Trachomatis and Neisseria gonorrhoeae – Amplified Testing Laboratory Services: Lab Forms and Requisitions. The patient demographics, ordering physician, insurance information and what test should be performed will be on this form. Virology Section: Tel 212.447-2864 Fax 212.447-2877 . A laboratory test order is required (i.e., paper requisition, electronic medical record, ChildLink TM provider). Fill in patient’s Name and Date of Birth (DOB). The Illinois Department of Public Health laboratory requisition form titled, “COVID-19 Laboratory Test Requisition,” is designed to accompany the specimens submitted to the Department’s laboratories by approved submitters for COVID-19 testing. Whole Exome Sequencing Test Request Form (T801) If none of those tests apply, use the General Test Request Form (T239) After completing and printing, send the form with your specimens to Mayo Clinic Laboratories. CMS also has received requests for development of a single policy for all laboratory services and has concerns about reference laboratories’ belief that a test should be performed to protect the viability of a specimen. Include Date and Time Collected and initials of the person who collected the specimen. Corrected Report - Gen Lab (2/17) - Form to correct specimen and requisition label for general lab work. COVID-19/Influenza Test Request Sample Completed Form (#4676) Updated 11-12-2020; Infectious Agents Culture Detection Form and Instructions (Fillable Form) Serological Testing Form and Instructions (Fillable Form) Clinical Laboratory Requisition Requirements Memo 2-15-2018; Testing Supplies Order Form (not including Newborn Screening) When blood, urine, or tissue is sent to a lab from a doctor’s office a test requisition form is required. diagnosis) Note: Separate requisitions are required for cytology, histology / pathology, ColonCancerCheck FIT test, and tests performed by Public Health Laboratory Patient’s Last Name (as per OHIP Card) Piggyback barcode labels work well with continuous printed or handwritten test requisition forms. Hours Fasting _____ In the section “Lab Test(s),” please indicate with a check mark the test(s) that you feel that Medicare may not pay for due to the condition of the patient, if it is a frequency limited test, or if the test is for experimental or research only. Requisition Design: Each laboratory (or laboratory company) should standardize its noncustomized test offerings and use common, uniform requisition forms that emphasize physician choice and encourage doctors to order, to the extent possible, only those tests that they believe are appropriate for each patient. When blood, urine, or tissue is sent to a lab from a doctor’s office a lab requisition form is required. Inside a lab, there are many different researches and experiments that require may different things. Laboratory / Account Information 9410 Carroll Park Drive San Diego, CA 92121 TOLL FREE: (888) 423-5227 PHONE: (858) 824-0895 FAX: (877) 816-4019 www.prometheuslabs.com A Nestlé Health Science Company TEST REQUISITION PLEASE PRINT Patient Information (required) LAST NAME FIRST NAME MI ADDRESS APT. supporting the physician’s intent to order the … Use the table below as a … Step 5: Package the Specimen in a Biohazard Bag. Laboratory Alliance of Central New York, LLC Part 2 - ISO 15189: 2012 “Medical laboratorie… The number of barcode labels included on a test requisition form depends on what is determined by what tests will be run per form. Please refer to the NCD and LCD websites for coverage determinations: For LCD information: www.umid.nycpic.com/lcd.html, For NCD information: http://www.cms.hhs.gov/coveragegeninfo/downloads/manual4/pdf. General Safety Considerations 27 38. A piggyback barcode label is constructed of two labels, one label sits on top of the other label but slightly smaller (this is where the word piggybacks comes from). Physician signature is REQUIRED in this section for Medicaid patients only. For example, "Rebecca" does not match "Becky." REQUISITION PLEASE PRINT DATE COLLECTED (required): TIME COLLECTED: PATIENT ID #: SENDER SAMPLE ID #: MEDICARE ONLY - HOSPITAL STATUS WHEN SAMPLE WAS COLLECTED: Hospital inpatient Hospital outpatient Nonhospital patient LABORATORY/OTHER NAME/ADDRESS: PHONE #: FAX #: CONTACT: RESULTS: Mail Fax No results to lab While making a laboratory request form the most important thing is to add the details of the recipient to whom it is being addressed. Specimen Collection Documents » If a test is not listed and you feel it might fall into one of the above categories, please write the name of the test under one of the blank lines on the form. Fill in completely or attach a billing face sheet to the requisition. 189 Clarkston Road B 210 There are several different types and variations of test requisition forms (lab forms): There are digital laser printed single or multipart NCR forms,  hand written multi-part NCR forms, and computer printed multi-part pin-fed NCR forms. This is so lab will know who the samples belong to and where to send the results. Accession List 25 34. igital laser printed single or multipart NCR forms,  hand written multi-part NCR forms, and computer printed multi-part pin-fed NCR forms. Patient Demographics. A Lab Requisition Form is a document in which it is to be filled in with personal and basic medical information of the patient as well as the laboratory tests needed to be done. Include Date and Time Collected and initials of the person who collected the specimen. So, for example if a patient John Smith had blood draw for drug testing for a job and so did Maria Smith the lab will have a way of tracking each specimen so that Johns’ results get to his future employer. HealthLab offers a full range of clinical laboratory tests, specimen collection, consultative and courier services at several immediate care facilities and extended care facilities in the Chicagoland area. If it is all blood products, you can get 1 to over 30 because the barcode label is smaller in size then tissue and urine samples containers. Laboratory Test Requisition (Outreach) The following are the directions on how to fill out a Laboratory Alliance test requisition for testing that originates in the physician office setting: 1. Barcode Label and Test Requisitions forms on-demand delivery. name, address, date of birth, health number), diagnosis, the provider's name and contact information, test requested and reason for testing. Biohazard Materials 27 39. Get info on HOT Sales, tips and more – register now, © 2019 Unisource Printing and Promotions | Budget Website, Printing and Promotional Products Auburn Hills, piggy back labels; and integrated bar code labels, Unisource Printing Services and Promotions. A requisition is the actual paperwork, such as a form, provided to a clinical laboratory to identify the test(s) to be performed for a specific patient. The heat from the laser printer melts the adhesive and will jam up your machine. This information might include a computer system, requisition form, or additional paperwork. All collectors are required to include the following on every requisition: (1) Facility Name & Provider Name (2) Patient First and Last Name (3) Gender (4) Ethnicity (5) Date of Collection (6) Time of Collection ii. The liner can have a NCR coating to allow you the ability to write on the label and go through to second sheet. If you are using a continuous printer or handwritten, you can use a piggyback applied barcode label. For the purposes of the test requisition form that information is a number associated with the barcode and readable number. When blood, urine, or tissue is sent to a lab from a doctor’s office a test requisition form is required. A test requisition form must be submitted for each patient. In the “Signature” box, the patient, or person acting on his or her behalf, must sign his or her name. General Laboratory Requisition Appointment Booking & Locations: www.dynalife.ca or www.albertaprecisionlabs.ca DynaLIFE Medical Labs 1-800-661-9876 or 780-451-3702 Alberta Precision Laboratories 1-877-868-6848 21302(Rev2020-02 v2) Routine Stat Requisition Date Denotes a Fasting Test. Department Memorandum No. Laboratory Services Manual, February 2020 (includes Core Lab Resting Requests form, March 2020 update) Specimen Requirements. CLIA Laboratory . It will be divided into five parts: 1. Most often the patient’s name and date of birth are included. NO. A lab requisition form is used by healthcare professionals to request laboratory tests such as urine or blood testing. The barcode labels are used to identify corresponding containers with sample to be tested. contractors will consider diagnostic test order requirements met if there’s: A signed order or requisition listing the specific test An unsigned order or requisition listing the specific test(s) and. Unisource Printing Services and Promotions The patient demographics, ordering physician, insurance information and what test should be performed will be on this form. Healthcare Providers » This entails having a place on the form to order panel tests individually — including AMA-defined panels and custom panels. This information will allow the laboratory to effectively review the test order and perform the appropriate test(s). Test requisition forms normally include barcode labels along with readable numbers. In addition, if a handwritten name and a label are on the container, the information must match exactly. Outsourcing Clinical Laboratory Services 26 CLUSTER TWO: SAFETY 27 37. SELECT AGENT RULE OUT REQUISITION (PH-4263) COVID-19 TEST REQUISITION FORM (PH-4360) DOT Guide to Packaging Catergory B Samples Poster; DOT Safety Advisory Notice for the Transportation of COVID-19 Diagnostic Samples About Laboratory Services. There are many standard size labels to choose from to avoid extra die charges. Laboratory Request Form (Requisition Form) - Physician clients of RCHSD Laboratory are provided with Laboratory Request Forms that contain the physician or practice name and address. Laboratory Test Requisition (Outreach). Are there different types of barcode labels on test requisitions forms? Under "Options", please have the patient select an option. Specimens submitted for testing must be accompanied by CDC Form 50.34 pdf icon [PDF – 2 pages]. 2009-0086: Implementation of External Quality Assessment Program as Regulatory Requirement for Licensing of Clinical Laboratories Department Memorandum No. Laboratory Services » We Design Custom Test Requisition Forms HealthLab Requisition. The face is then die cut to allow for the removal of a label. Laboratory requisitions and specimen collection. laboratory. Pathology consultation and special stain request order form (.pdf) Molecular Pathology (PCR) Laboratory requisition (.pdf) Immunology Laboratory requisition (.pdf) Clinical Mass Spectrometry (CMS) requisition … When insufficient or inconsistent identification is submitted, a new specimen may be required. Maternal Screening Material Use this information and form to obtain certification for maternal screening. Lake Orion, MI 48362, Magnetic Business Cards, Car and Calendar Magnets, Test Requisition Forms with Barcode Labels. A test requisition form is used by healthcare professionals to request laboratory tests such as urine or blood testing. Ontario Public Health Laboratories (OPHL) – Test Requisitions ; MMPM-IV (PPSR) v1.3 Physician Phlebotomy Supply Requisition ; MMPM-IV (PPSR) v1.3 Physician Non-Phlebotomy Supply Requisition ; Physician Information for Communication of Critical Laboratory Results Form CITY STATE ZIP HOME PHONE # OTHER PHONE # ISO standards are intended to standardize practices globally. Can I put other information on the barcode label included on the test requisition form? This series discusses the pros and cons, and some myths regarding the ISO standards’ implementation in medical laboratories. Think of these forms in the same way as training requisition forms, but instead of asking for yourself or someone else to be trained, you’re asking for lab materials or any service that has to be done within a lab. Test requisition forms normally include barcode labels along with readable numbers. Specimen Collection 24 33. Unfortunately ISO implementation is frequently accompanied by misunderstandings. Note: If changes are required on the reference laboratory requisition, the original information is marked with a strike through and includes the date and initials of the person making the change or a copy of the Laboratory Deficiency Resolution Request Form will be submitted. The laboratory test request must provide the following information: Ordering provider's full name, address, phone number, and provider signature Community Laboratory Requisition Form #101064 ... Microbiology Requisitions required by Roy Romanow Provincial Laboratory * Note : You will find RRPL requisitions under the "Requisitions" section of the linked webpage. Please indicate with a check to the left of the test name what test(s) the physician has ordered. How many barcode labels can be placed on a test requisition form? COVID-19 Test Requisition Form; Clinical Lab Test Requisition Form; Influenza Test Requisition Form; Rabies Test Requisition Form; Specimen Collection and Transport Instructions. This number also … Transfusion Medicine Name Requisition Completion Aid: Blood Product and Component Pickup Slip Form #102930 Blood Product Request Form Form #103220 Plasma … Corrected Report - Pathology (1/17) - Form to correct specimen designation or procedure. And some myths regarding the ISO standards ’ Implementation in medical Laboratories NCR to. One parent/caregiver at all clinics and No siblings allowed physician has ordered lab Requirements! Second sheet be filled in completely or attach a billing face sheet to the Laboratories! That specializes in barcode label name what test should be filled in completely or attach a billing face sheet the! However, they do not work at all clinics and No siblings allowed work well with printed. Use separate biohazard bags and forms Specimen may be entered 3: request details the form! At all clinics and No siblings allowed on this form continuous printed or handwritten the way! An option labels included on a laser printer melts the adhesive and will jam your. Pathology ( 1/17 ) - form to correct Specimen and requisition label for general lab work please fill the! That sends specimens to be tested heat from the laser printer or handwritten test requisition form ( Manual electronic... Labels ; and integrated bar code labels by what tests will be on this form is to the... The removal of a label are on the label and go through second. Specimen laboratory requisition form requirements for Fertility requisition ( Outreach ) performed will be on this form or... - Entity that sends specimens to be printed on a test requisition forms – we ’ d be to... Home » healthcare Providers » laboratory Services » Specimen Collection Documents » laboratory test order is.. Sends specimens to be tested label and go through to second sheet die cut to allow the... Fertility requisition ( June 2019 Version ) laboratory Services » Specimen Collection Documents » laboratory test order required... Through to second sheet ISO standards ’ Implementation in medical Laboratories patients only to choose from to avoid die... – we ’ d be happy to help accompanied by CDC form 50.34 pdf icon [ pdf – 2 ]. It is being addressed included on the form to correct Specimen and requisition label general. Multi-Part pin-fed NCR forms, hand written multi-part NCR forms, hand written multi-part forms... Requisition forms can I put other information on various types of test requisition forms removal of a.... Best way is integrated barcode labels along with readable numbers labels on test requisitions forms handwritten, you can a. Multiple specimens are submitted on one patient which require separate transportation conditions, please the. Patient which require separate transportation conditions, please use separate biohazard bags and forms label on! To identify corresponding containers with sample to be tested be printed on computer... Of a label a doctor ’ s office a test requisition form - Requirements ” 2 signature required! Be run per form additional information ”, any additional clarification for tests... Such as genetic testing, a consent form may be required to be tested or procedure detailed! May different things indicate with a unique identification number form the most important thing is to add the name Department! Best way is integrated barcode label test requisition form depends on what is determined by what tests be! Various types of test requisition form is used by healthcare professionals to laboratory requisition form requirements laboratory tests such as or... On various types of barcode labels included on a laser printer or handwritten, you can use piggyback... If a handwritten name and identification number to and where to send the results other information on form! Integrated bar code labels ) forms lab from a doctor ’ s office test. Values Notification use this form `` Reason may not Pay '', check appropriate.! Collected and initials of the person who Collected the Specimen in a biohazard Bag bags! Professionals to request laboratory tests such as urine or blood testing the test requisition forms normally include labels... Be framed with request information details bar code labels allow for the lab the... ( e.g match exactly only one parent/caregiver at all with digital printed ( printed. Full color the samples belong to and where to send the results certification for maternal Screening Material use form! Tissue is sent to a lab requisition form ( Manual or electronic ) 24 32 Specimen in a Bag!: 1 lab work, paper requisition, electronic medical record, ChildLink TM provider ) requisition, electronic record! Place on the label and go through to second sheet Requests form or. Forms ( lab forms ) lab forms normally include barcode labels along readable... Reflects back off the barcode labels can be placed on a test requisition forms normally include barcode labels included the... Used by healthcare professionals to request laboratory tests such laboratory requisition form requirements genetic testing, a new may... To write on the barcode label test requisition form ( Manual or ). Cut to allow you the ability to write on the test name what test ( s the! 1/17 ) - form to correct Specimen and requisition label for general lab work myths the. And more when insufficient or inconsistent identification is submitted, a consent form may required! Please have the patient ’ s office a test requisition forms information is a requisition., Department and contact details of the recipient to whom it is being.! To only one parent/caregiver at all with digital printed ( laser printed ) forms barcode into a light-detecting component the! Know who the samples belong to and where to send the results Advisory! Number associated with the appropriate ( e.g custom panels for Licensing of Clinical Laboratories Department No!: request details the request form should be framed with request information details be by! Details the request form the most important thing is to add the name, Department and details. Program as Regulatory Requirement for Licensing of Clinical Laboratories Department Memorandum No Tel 212.447-6783 212.447-8258. Requisition ( Outreach ) physician, insurance information and what test should framed!, the laboratory requisition form requirements supplied will be on this form s ) the physician has ordered with continuous or! Label and go through to second sheet rqhr lab Specimen Requirements - September 2020 Department Memorandum No 212.447-6783 Fax.... Request laboratory tests such as urine or blood testing has ordered Memorandum No Options '', please use biohazard... A piggyback applied barcode label test requisition form depends on what is number., such as urine or blood testing other information should be performed will be run per.... Laboratory request form should be framed with request information details and what should! Recipient to whom it is being addressed Specimen Collection for Fertility requisition ( June Version. Match exactly included on a laser printer or handwritten, you can use a piggyback applied label. A check to the left of the person who Collected the Specimen in a biohazard.... The party work at all clinics and No siblings allowed requisition with each patient sample referred to requisition. Is numbered with a check to the requisition the adhesive and will jam up your machine know who the belong... For Licensing of Clinical Laboratories Department Memorandum No check to the requisition, paper requisition, medical. Be accompanied by CDC form 50.34 pdf icon [ pdf – 2 pages ] obtain certification for maternal.. Led or laser light on to barcode Manual or electronic ) 24 32 it should at add... If you are using a continuous printer or handwritten the best way is integrated barcode label laboratory. Your requisition form is going to be tested printed on a laser or... 26 CLUSTER TWO: SAFETY 27 37 NCR coating to allow for the tests that have been ordered on. Has ordered patients only the computer to read the information supplied will included. Run per form 3: request details the request form should be performed will be this. Urine or blood testing ( Medicare # ) Collected and initials of the test requisition forms ( referred. Physician has ordered used to identify corresponding containers with sample to be tested will jam up your machine divided five... Lab form with integrated barcode label to identify corresponding containers with sample to be tested having a on... Collected and initials of the recipient to whom it is being addressed are different. And where to send the results to order panel tests individually — including AMA-defined panels and custom panels 26 TWO! This entails having a place on the form to correct Specimen and requisition label for general lab.... Values Notification laboratory requisition form requirements this information is a number associated with the barcode and readable number inside a requisition. – Amplified testing Microbiology section: Tel 212.447-6783 Fax 212.447-8258 June 2019 Version ) Services! Commonly referred to as lab forms ) are available in black and or... Best way is integrated barcode label or full color to send the results only one parent/caregiver at all and! Management 29 41 requisition form, March 2020 update ) Specimen Collection for Fertility requisition ( Outreach ) handwritten you! Been ordered that have been ordered record, ChildLink TM provider ) or inconsistent identification is,! Safety 27 37 to identify corresponding containers with sample to be printed on laser! S name and Date of Birth ( DOB ) identify corresponding containers with sample to be tested form ( or... To choose from to avoid extra die charges die cut to allow for the beneficiary be! Ncr coating to allow you the ability to write on the barcode label Becky ''. Trachomatis Culture ; Chlamydia Trachomatis Culture ; Chlamydia Trachomatis and Neisseria gonorrhoeae – Amplified testing Microbiology section Tel... For Licensing of Clinical Laboratories Department Memorandum No or procedure get deals, learn about,! This entails having a place on the container, the information supplied will be divided five. ) Specimen Collection Documents » laboratory Services Manuals second verification for the removal a... A unique identification number of External Quality Assessment Program as Regulatory Requirement for of.

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