
For questions regarding tube types or other specimen collection issues, call the Laboratory Client Services Dept. at 303-404-4050 M-F 8am-6pm
Reorder form # 00254730 Kaiser Permanente form updated on 6/07
Community Physician LABORATORY REQUISITION
UPIN / NPI#_____________________
Provider Name:
_______________________________________________
______________________________________________
ADDRESS:__________________________________________
PHONE NUMBER:____________________________________
SECURE FAX NUMBER:_______________________________
**Required**
FILL IN ALL INFORMATION
ノ MALE
ノ FEMALE DATE OF BIRTH:______________________
PATIENT NAME: LAST, FIRST
_____________________________________________________________________
(KAISER MEDICAL RECORD #____________________________________________
ニ NON- FASTING ニ STAT ニ ASAP
ニ FASTING HOURS _____ ニ ROUTINE
**Medicare does not generally cover routine screening tests.
Providers FAX this signed and dated form to: 303-404-4030
[ URINALYSIS
ニ
81003 UA reflex MICRO if positive- 81002
ニ 87088 URNC/CULTURE (reflexed as indicated)
[ HEMATOLOGY
ニ 85025 CBC/AUTO DIFF(man diff reflexed if meets criteria)
ニ 85652 ESR - SED RATE
ニ
85014/85018 Hemoglobin & Hematocrit
ニ
85046 RETICULOCYTE
[ COAGULATION LB/SP1 L
ニ
85610 PT PROTIME / INR
ニ
85730 PTT APTT
[ CHEMISTRY PROFILES
ニ
80048 BMP Chem 7 (LYTES,BUN,CREAT,GLU,CA)
ニ 80053 CMP Comp Metatobolic Prof (BMP,HFP,TP)
ニ 80061 FLIPP FASTING (CHOL,TGL,HDL,LDL)
ニ 83550 / 83540 IRPF Iron Panel (FE,IBC,TIBC,TRANS SAT)
ニ 80076 HFP Hepatic Function Panel
(ALB,AST,ALT,ALKP,TBIL/DBIL)
ニ 80051 LYTES ( NA,K,CL,CO2)
ニ 80069 RFP (LYTES,BUN,CR,GLU,CA,ALB,PHOS)
ニ 84443 THYP FT4 reflexed if TSH abnormal
FT3 reflexed if TSH low and FT4 norm
[ CHEMISTRY SINGLE TESTS
ニ
84460 ALT (SGPT)
ニ
82150 AMYLASE
ニ
84450 AST (SGOT)
ニ
82247 BILIRUBIN, TOTAL- ADULT
ニ
84520 BUN
ニ
82310 CALCIUM
ニ
82550 CPK
ニ
82565 CREATININE
ニ
82728 FERRITIN
ニ
82746 FOLATE R
ニ 82947 GLUCOSE, ___HRS PP
ニ
83036 HEMOGLOBIN A1C LAV
ニ 84132 POTASSIUM
ニ
83690 LIPASE
ニ 83735 MAGNESIUM
ニ
84100 PHOSPHORUS
ニ 83970/82310/82565/84100
PTHINT INTACT PTH-Fasting preferred SST & LAV
ニ 82043 / 82570 RMA RAND URINE PROT/CREAT RATIO
ニ 84295 SODIUM
ニ
84443 TSH
ニ
84550 URIC ACID
ニ
82607 VITAMIN B12
ニ
82746/82607 VITAMIN B12/FOLATE
[ THERAPEUTIC DRUGS
DATE AND TIME OF LAST DOSE:
ニ
80162 DIGOXIN
ニ
80185 DILANTIN R
ニ
80170 GENTAMYCIN
ニ PEAK ニ TROUGH
ニ 80178 LITHIUM
ニ
80156 TEGRETOL (CARBAMAZEPINE)
ニ
80164 VALPROIC ACID (DEPAKOTE)
ニ
80202 VANCOMYCIN
ニ PEAK ニ TROUGH
[ SPECIAL CHEMISTRY
ニ
86592 RPR SYPHLIS SCREEN
ニ
84165 SPEP SERUM PROT ELECTROPHORESIS
ニ 86706 HEPATITIS B SURFACE AB
[ OTHER TESTING
ニ GLUCOSE TOLERANCE (OB)
ニ 82950 1 HOUR
ニ 82947 (X2) 2 HOUR POST MEAL
ニ 82947 (X4) 3 HOUR TOLERANCE
ニ 84703
SERUM PREG
ニ 81025 URINE PREG
ニ 84702 BETA HCG QUANT
ニ 82670 ESTRADIAL
ニ 84144 PROGESTERONE
ニ 83001 (+ 83002) LH/FSH
[ 24 HOUR URINE TESTS
ニ
82575 CRCL CREAT CLEARANCE W/ SERUM
ニ 82340 UCA CALCIUM
ニ
84166 UPEP URINE PROTEIN ELECTROPHORESIS
ニ 84156 UPROT TOTAL URINE PROTEIN
24 hour urine containers can be picked up at any Kaiser
Permanente laboratory location.
No appointments necessary for routine
laboratory testing at any Kaiser
Permanente lab facility
No specimens will be accepted at any
Kaiser Permanente facility
To Order Any Other Test,
Provider must call: 303-743-5330
The tests on this requisition have been approved by the
attending physician.
Provider signature Date
DRAW SITE _________# OF STICKS ________
UNABLE TO DRAW _________ Physician notified? YES NO
SST__________ LAVENDER_________ RED_________ BLUE_________ GREEN_________ GRAY_________ URINE_________ STOOL_________SWAB__________
COMMENTS: LABORATORY LOCATION RECEIVED BY: