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The Lab Requisition form is an essential document used by healthcare providers to request laboratory tests for patients. This form includes key information such as the provider's name, contact details, and unique identification numbers. It also requires the patient's demographic information, including their name, date of birth, and gender. A critical section of the form is dedicated to diagnosis codes, which are necessary for insurance billing and determining test coverage. The requisition outlines various tests, categorized into groups like urinalysis, hematology, and chemistry profiles. Each category lists specific tests that can be ordered, along with any special instructions, such as whether the patient needs to fast before testing. Additionally, the form includes sections for therapeutic drug monitoring and special chemistry tests. Providers must sign and date the form, confirming that the requested tests have been approved. Clear instructions for submitting the form and additional contact information for lab services are also provided, ensuring a smooth process for both providers and patients.

Preview - Lab Requisition Form

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**
ICD 9 DIAGNOSIS CODE
(s):
FILL IN ALL INFORMATION
MALE
FEMALE DATE OF BIRTH:______________________
PATIENT NAME: LAST, FIRST
_____________________________________________________________________
(KAISER MEDICAL RECORD #____________________________________________
NON- FASTING STAT ASAP
FASTING HOURS _____ ROUTINE
**Medicare does not generally cover routine screening tests.
Providers FAX this signed and dated form to: 303-404-4030
URINALYSIS
81003 UA reflex MICRO if positive- 81002
87088 URNC/CULTURE (reflexed as indicated)
HEMATOLOGY
85025 CBC/AUTO DIFF(man diff reflexed if meets criteria)
85652 ESR - SED RATE
85014/85018 Hemoglobin & Hematocrit
85046 RETICULOCYTE
COAGULATION LB/SP1 L
85610 PT PROTIME / INR
85730 PTT APTT
CHEMISTRY PROFILES
80048 BMP Chem 7 (LYTES,BUN,CREAT,GLU,CA)
80053 CMP Comp Metatobolic Prof (BMP,HFP,TP)
80061 FLIPP FASTING (CHOL,TGL,HDL,LDL)
83550 / 83540 IRPF Iron Panel (FE,IBC,TIBC,TRANS SAT)
80076 HFP Hepatic Function Panel
(ALB,AST,ALT,ALKP,TBIL/DBIL)
80051 LYTES ( NA,K,CL,CO2)
80069 RFP (LYTES,BUN,CR,GLU,CA,ALB,PHOS)
84443 THYP FT4 reflexed if TSH abnormal
FT3 reflexed if TSH low and FT4 norm
CHEMISTRY SINGLE TESTS
84460 ALT (SGPT)
82150 AMYLASE
84450 AST (SGOT)
82247 BILIRUBIN, TOTAL- ADULT
84520 BUN
82310 CALCIUM
82550 CPK
82565 CREATININE
82728 FERRITIN
82746 FOLATE R
82947 GLUCOSE, ___HRS PP
83036 HEMOGLOBIN A1C LAV
84132 POTASSIUM
83690 LIPASE
83735 MAGNESIUM
84100 PHOSPHORUS
83970/82310/82565/84100
PTHINT INTACT PTH-Fasting preferred SST & LAV
82043 / 82570 RMA RAND URINE PROT/CREAT RATIO
84295 SODIUM
84443 TSH
84550 URIC ACID
82607 VITAMIN B12
82746/82607 VITAMIN B12/FOLATE
THERAPEUTIC DRUGS
DATE AND TIME OF LAST DOSE:
80162 DIGOXIN
80185 DILANTIN R
80170 GENTAMYCIN
PEAK TROUGH
80178 LITHIUM
80156 TEGRETOL (CARBAMAZEPINE)
80164 VALPROIC ACID (DEPAKOTE)
80202 VANCOMYCIN
PEAK TROUGH
SPECIAL CHEMISTRY
86592 RPR SYPHLIS SCREEN
84165 SPEP SERUM PROT ELECTROPHORESIS
86706 HEPATITIS B SURFACE AB
OTHER TESTING
GLUCOSE TOLERANCE (OB)
82950 1 HOUR
82947 (X2) 2 HOUR POST MEAL
82947 (X4) 3 HOUR TOLERANCE
84703
SERUM PREG
81025 URINE PREG
84702 BETA HCG QUANT
82670 ESTRADIAL
84144 PROGESTERONE
83001 (+ 83002) LH/FSH
24 HOUR URINE TESTS
82575 CRCL CREAT CLEARANCE W/ SERUM
82340 UCA CALCIUM
84166 UPEP URINE PROTEIN ELECTROPHORESIS
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:

Document Specifics

Fact Name Fact Description
Provider Identification The form requires the community physician's UPIN or NPI number for identification.
Patient Information Essential patient details include name, date of birth, and gender.
Diagnosis Codes ICD-9 diagnosis codes must be filled in, as Medicare does not cover routine screening tests.
Test Options The form lists various tests, including urinalysis, hematology, and chemistry profiles.
Fasting Requirements Providers can specify whether tests require fasting or if they are non-fasting.
Submission Instructions Providers must fax the signed and dated form to the designated laboratory number.
Special Testing Includes specialized tests such as therapeutic drug monitoring and glucose tolerance tests.
Sample Collection Routine laboratory testing does not require appointments at Kaiser Permanente facilities.
Reorder Information The form includes a reorder number for tracking and resubmission purposes.
Governing Law Specific state laws may apply to laboratory requisition forms; check local regulations for compliance.

Lab Requisition: Usage Instruction

Filling out the Lab Requisition form is a straightforward process. Once completed, this form will be sent to the lab for testing. Ensure all information is accurate to avoid any delays in processing. Follow these steps to fill out the form correctly.

  1. In the top section, enter the UPIN / NPI# of the community physician.
  2. Write the Provider Name in the designated space.
  3. Fill in the ADDRESS of the provider.
  4. Provide the PHONE NUMBER and SECURE FAX NUMBER.
  5. List the ICD 9 DIAGNOSIS CODE(s) as required.
  6. Indicate the patient’s gender by marking either MALE or FEMALE.
  7. Fill in the DATE OF BIRTH of the patient.
  8. Write the PATIENT NAME in the format of LAST, FIRST.
  9. If applicable, enter the KAISER MEDICAL RECORD #.
  10. Select the appropriate options for FASTING and urgency (STAT, ASAP, or ROUTINE).
  11. Choose the tests required by checking the corresponding boxes.
  12. For any THERAPEUTIC DRUGS, indicate the DATE AND TIME OF LAST DOSE.
  13. Fill in the DRAW SITE and the number of sticks attempted.
  14. Note if the draw was successful or if the physician was notified.
  15. Include any COMMENTS if necessary.
  16. Finally, the provider must sign and date the form.

Learn More on Lab Requisition

What is a Lab Requisition Form?

A Lab Requisition Form is a document that healthcare providers use to request laboratory tests for their patients. This form includes essential information such as the patient's details, the specific tests needed, and the physician's information. It ensures that the lab has all the necessary data to process the tests accurately and efficiently.

How do I fill out the Lab Requisition Form?

Filling out the Lab Requisition Form is straightforward. Here are the key steps:

  1. Start with the provider's information, including their UPIN or NPI number, name, address, and contact details.
  2. Enter the patient's information, including their name, date of birth, and gender.
  3. Specify the ICD 9 diagnosis code(s) to explain the medical reason for the tests.
  4. Select the type of tests required from the provided list and indicate any special instructions, such as fasting or STAT requests.
  5. Finally, the provider must sign and date the form before sending it to the lab.

What should I do if I have questions about the tests?

If you have questions regarding the tests or need clarification about the requisition form, you can contact the Laboratory Client Services Department at 303-404-4050. They are available Monday through Friday from 8 AM to 6 PM and can assist with any inquiries related to specimen collection or tube types.

How do I submit the Lab Requisition Form?

Once the Lab Requisition Form is completed, it should be faxed to the designated number: 303-404-4030. It’s important to ensure that the form is signed and dated by the provider to avoid any delays in processing the tests. Remember, no specimens will be accepted directly at any Kaiser Permanente facility, so faxing is the preferred method.

Common mistakes

Filling out a Lab Requisition form accurately is crucial for ensuring that patients receive the correct tests and diagnoses. However, several common mistakes can lead to complications. Recognizing these errors can help streamline the process and improve patient care.

One frequent mistake is failing to include the ICD-9 diagnosis code(s). This information is essential for insurance coverage and proper test justification. Omitting this code can result in delays or denials of coverage, causing unnecessary stress for patients and providers alike.

Another common error involves not filling in the patient’s date of birth. This detail is vital for identifying the patient and ensuring that the correct medical history is considered. Without it, there could be confusion, especially if multiple patients have similar names.

Inaccurate patient information, such as the patient's name or address, can also create significant issues. If the name is misspelled or the address is incorrect, it may lead to miscommunication and delays in receiving test results. Always double-check this information before submission.

Additionally, providers sometimes forget to indicate the gender of the patient. This detail is important for certain tests and can affect the interpretation of results. It is essential to mark the appropriate box to avoid any confusion later.

Another mistake involves not specifying the test urgency. Whether the tests are routine, STAT, or require fasting can impact how quickly results are processed. Failing to indicate this can lead to mismanagement of the patient's care.

Many also overlook the importance of the provider's signature and date. This confirmation is necessary to validate the requisition. Without it, the laboratory may not proceed with the tests, leading to delays in diagnosis and treatment.

Lastly, providers often forget to include comments or special instructions in the designated section. This can be particularly important for unique patient circumstances or specific testing requirements. Including this information can help laboratory staff better understand the context of the tests being ordered.

By being aware of these common mistakes, providers can ensure that the Lab Requisition form is filled out correctly. This attention to detail not only facilitates a smoother testing process but also enhances the overall quality of patient care.

Documents used along the form

When a healthcare provider orders lab tests, several forms and documents often accompany the Lab Requisition form to ensure a smooth process. Each document plays a crucial role in facilitating communication between the provider, the laboratory, and the patient. Understanding these documents can help streamline the testing process and improve patient care.

  • Patient Consent Form: This document confirms that the patient has been informed about the tests being conducted and agrees to them. It protects both the provider and the lab by ensuring that the patient understands the purpose and potential risks involved.
  • Insurance Information Form: This form collects details about the patient’s insurance coverage. It helps the lab determine whether the tests will be covered under the patient’s plan and ensures that billing is handled correctly.
  • Medical History Form: This document provides essential background information about the patient’s health. It may include previous conditions, medications, and allergies, which can be critical for interpreting lab results accurately.
  • Test Preparation Instructions: Often included with the requisition, this document outlines any necessary preparations the patient must follow before the test, such as fasting or avoiding certain medications.
  • Specimen Collection Guidelines: This guide details the proper procedures for collecting samples, ensuring that the specimens are collected in a way that maintains their integrity and reliability for testing.
  • Results Reporting Form: This document specifies how and when the lab will report test results back to the provider. Clear communication about results is essential for timely patient care.
  • Follow-Up Care Instructions: After testing, this form provides information on what the patient should do next, including any necessary follow-up appointments or additional tests that may be required based on the results.

By familiarizing yourself with these accompanying documents, you can enhance the efficiency of lab testing and improve overall patient outcomes. Each form contributes to a comprehensive approach to healthcare, ensuring that patients receive the best possible care throughout the testing process.

Similar forms

The Lab Requisition form shares similarities with a Prescription form, which is commonly used in healthcare settings. Both documents serve as a means of communication between healthcare providers and laboratories or pharmacies. A Prescription form includes essential patient information, medication details, and provider signatures, much like the Lab Requisition form captures patient demographics, provider information, and specific tests to be conducted. The primary function of both forms is to ensure that the right services are delivered to the right patients, reflecting the provider's clinical judgment.

Another document that resembles the Lab Requisition form is the Referral form. This form is utilized when a primary care physician refers a patient to a specialist for further evaluation or treatment. Similar to the Lab Requisition, the Referral form contains patient information, the referring provider's details, and specific reasons for the referral. Both documents aim to facilitate continuity of care, ensuring that all relevant information is communicated effectively to the receiving party.

The Patient Registration form also shares characteristics with the Lab Requisition form. This document collects vital information about the patient, including demographics, insurance details, and medical history. While the Lab Requisition focuses on laboratory tests, both forms are essential for establishing a patient's identity and ensuring that healthcare providers have the necessary information to deliver appropriate care. They are foundational documents that support the overall healthcare process.

In addition, the Consent form is akin to the Lab Requisition form in that it requires patient or guardian signatures to authorize specific medical actions. The Consent form typically outlines the procedures to be performed and any associated risks. Similarly, the Lab Requisition form indicates that the tests have been approved by the attending physician, ensuring that the patient is aware of the tests being conducted. Both documents emphasize the importance of informed consent in the healthcare setting.

The Medical History form can also be compared to the Lab Requisition form. This document gathers comprehensive information about a patient's past medical conditions, surgeries, and medications. While the Lab Requisition focuses on specific tests to be performed, both forms contribute to a complete understanding of the patient's health status. They ensure that healthcare providers have a thorough background to guide their clinical decisions.

A Laboratory Test Result form bears similarities to the Lab Requisition form as well. Once laboratory tests are completed, results are typically documented on this form, which includes patient information, test details, and findings. Like the Lab Requisition, the Test Result form is integral to the diagnostic process, providing healthcare providers with crucial information to inform patient care. Both documents play a role in the continuum of care, linking testing and diagnosis.

The Insurance Authorization form is another document that resembles the Lab Requisition form. This form is often required by insurance companies before certain tests or procedures can be performed. Similar to the Lab Requisition, it includes patient details and the specific services being requested. Both forms are essential for ensuring that the necessary approvals are in place for medical services, helping to streamline the billing and reimbursement process.

The Treatment Plan form is also comparable to the Lab Requisition form. This document outlines the proposed course of treatment for a patient, including any tests that may be necessary. Like the Lab Requisition, it requires input from the healthcare provider and serves as a roadmap for patient care. Both forms reflect the provider's clinical decision-making and are critical for ensuring that patients receive appropriate and timely interventions.

Finally, the Discharge Summary form can be likened to the Lab Requisition form. This document is prepared when a patient is discharged from a healthcare facility and includes a summary of the patient's treatment, follow-up care, and any necessary tests. Both forms serve to communicate important information about a patient's care, ensuring continuity as the patient transitions between different healthcare settings.

Dos and Don'ts

When filling out the Lab Requisition form, attention to detail is crucial. Here’s a list of things to do and things to avoid to ensure the process goes smoothly.

  • Do fill in all required information accurately, including provider name and contact details.
  • Do include the correct ICD 9 diagnosis code(s) to avoid delays in processing.
  • Do specify the patient's gender and date of birth clearly.
  • Do indicate any special instructions, such as fasting requirements, if applicable.
  • Do ensure the form is signed and dated by the provider before submission.
  • Don't leave any required fields blank; incomplete forms can lead to processing issues.
  • Don't use outdated codes or information; always check for the latest requirements.
  • Don't forget to specify the draw site and number of sticks, as this information is essential.
  • Don't submit the form without double-checking for any errors or omissions.
  • Don't send the form via an unsecured method; ensure it is faxed securely to the designated number.

Misconceptions

Misconceptions about the Lab Requisition form can lead to confusion for both healthcare providers and patients. Here are eight common misconceptions explained:

  • Only doctors can fill out the form. While physicians typically complete the requisition, other qualified healthcare providers may also fill it out, as long as they are authorized.
  • All tests require fasting. Not all tests require fasting. The form indicates whether fasting is necessary for specific tests, so it is important to check the requirements for each test.
  • Medicare covers all tests listed. Medicare does not cover routine screening tests in many cases. It is essential to verify coverage for each specific test.
  • The form is optional for routine tests. The requisition form is required for all laboratory tests to ensure proper identification and processing of samples.
  • Any healthcare facility can accept the form. Only Kaiser Permanente facilities accept this specific requisition form. Other locations may have different requirements.
  • Completing the form accurately is not important. Accurate completion is crucial for proper test processing and results. Missing information can lead to delays or errors.
  • All tests can be ordered without prior consultation. Some tests may require prior authorization or consultation with a specialist, depending on the patient's condition and insurance coverage.
  • Specimens can be dropped off at any time. Specimens must be submitted according to specific guidelines. Some locations may have designated hours for specimen drop-off.

Key takeaways

Filling out the Lab Requisition form correctly is essential for accurate testing and patient care. Here are some key takeaways to keep in mind:

  • Complete all sections: Ensure every field is filled out, including the provider's name, address, and contact information.
  • ICD 9 Diagnosis Code: Include the required diagnosis code, as Medicare may not cover routine tests without it.
  • Patient Information: Clearly write the patient's name, gender, and date of birth to avoid any confusion.
  • Test Selection: Carefully select the tests needed. Check the appropriate boxes and indicate any special instructions like fasting or STAT requests.
  • Signature Required: The form must be signed and dated by the provider to validate the tests ordered.
  • Submit Correctly: Fax the completed form to the designated number and ensure that it is sent securely.

By following these guidelines, you can help ensure a smooth process for laboratory testing and improve patient outcomes.