Laboratory Requisition

Work Form 28-1

Laboratory Requisition

PATIENT LAST NAME / FIRST / M.I. / REFERRING PROVIDER
PROVIDER ID # / PATIENT ID # / BILL: /  PHYSICIAN /  MEDICAL /  HMO /  CHDP / D.O.B. / AGE / SEX
 MEDICARE /  INSURANCE /  PATIENT
PLEASE COMPLETE INSURANCE INFORMATION AT BOTTOM
PROVIDER NAME, ADDRESS, AND PHONE NUMBER / PATIENT ADDRESSPATIENT PHONE NUMBER
( ) / DATE COLLECTED / TIME COLLECTED
CITYSTATEZIPCODE / FASTING / STAT / CALL RESULT
YES / NO
PATIENT MEDICARE # / PATIENT MEDICAID # / INFO. BELOW WILL APPEAR ON REPORT
CUSTOM PROFILES & ADDITIONAL TESTS
PROFILES
00011 /  SPECIAL COMPREHENSIVE / 2 SS,L / 03536 /  HYPERTHYROID PROFILE / SS
00001 /  COMPREHENSIVE HEALTH SURVEY / SS,L / 05037 /  HYPOTHYROID PROFILE / SS
00002 /  GENERAL SURVEY / SS,L / 05051 / LIPID PROFILE / SS
00003 /  CHEMISTRY PANEL / SS,L / 05021 /  LIVER PROFILE / SS
CH7 /  CHEM 7 PANEL / SS / 03359 /  LUPUS PROFILE / SS
03280 /  ANEMIA PROFILE / SS,L / 03959 /  MENOPAUSAL PROFILE / SS /03960 / POST MENOPAUSAL / SS
06016 /  ARTHRITIS PROFILE / SS,L / 02280 /  OVARIAN FUNCTION PROFILE / SS /02281 / TESTICULAR FUNC. PROF / SS
05725 /  COMPREHENSIVE THYROID SURVEY / SS / 02808 /  PRENATAL PROFILE / L,R
02691 /  EPSTEIN BARR PROFILE / SS / 05006 / THYROID PROFILE / SS
05010 /  ELECTROLYTES / SS / 03191 /  TORCH PANEL / SS
06826 /  HEPATITIS PROFILE / SS / 5756 /  URINE DRUG SCREEN / U / / VENIPUNCTURE
TESTS
0361 ABO & Rh TYPE / R,L / 0141 C-REACTIVE PROTEIN / SS / 0673  HEPATITIS B SURFACE ANTIGEN / SS / 0237 PTT / B
0302 ALKALINE PHOSPHATASE / SS / 1341 DHEA-S / SS / 0245  HEPATITIS C ANTIBODY / SS / 0317 RA FACTOR / SS
0109 AMYLASE / SS / 0119 DIGOXIN / SS / 0257  IRON / SS / 0321 RUBELLA / SS
0613 ANA / SS / 0224 DILANTIN / SS / LDL-A LDL CHOLESTEROL / SS / 0331 RPR / SS
0366 ANTIBODY SCREEN / R / 0835 ESTRADIOL / SS / 0283  LEAD BLOOD / RB / 0335 SEMEN ANALYSIS / SEMEN
0110 ASO (STREPTOZYME) / SS / 0833 FERRITIN / SS / 0281  LIPASE / SS / 0328SEDIMENTATION RATE (ESR) / L
0126 BILIRUBIN TOTAL / SS / 0003 FOLIC ACID & VITAMIN B12 / SS / 8225  LH / SS / 0349 SGOT (AST) / SS
0132 BUN / SS / 0651 FSH / SS / 0247  MONONUCLEOSIS / SS / 0348 SGPT (ALT) / SS
8726 CA125 / S / 0140 FTA-ABS / SS / 0778  PHENOBARBITAL / SS / 0330SICKLE CELL SCREEN / L
0142 CALCIUM / SS / 0210 GGTP / SS / 0307  POTASSIUM / SS / 0354 T4 (THYROXINE) / SS
0130 CBC / L / 0536 GLUCOSE, FASTING / GY / 0557  PREGNANCY (SERUM) / SS / 1358 T4 FREE / SS
0388 CEA-ROCHE / SS /  GLUCOSE, ______HR PP / GY / 0308  PREGNANCY (URINE) / U / 8456 TESTOSTERONE / SS
0152 CHOLESTEROL / SS / 0771 GLYCOHEMOGLOBIN / L / 0359  PROGESTERONE / SS / 0824 THEOPHYLLINE / SS
0788 CORTISOL / SS / 0534 H. PYLORI / SS / 8041  PROLACTIN / SS / 0360 TRIGLYCERIDE / SS
0162 CPK / SS / 0823 HGG QUANTITATIVE / SS / 0103  PROTEIN, TOTAL / SS / 0672 TSH / SS
0445 CKMB ISOENZYME / SS / 1856 HIV (ANTIBODY) / SS / 2000  PROSTATE SPECIFIC ANTIGEN (PSA) / SS / 0373 URIC ACID / SS
0161 CREATININE / SS / 0558 HDL CHOLESTEROL / SS / 0310  PT (PROTHROMBIN TIME) / B / 0219 URINALYSIS / U
CYTOPATHOLOGY / MICROBIOLOGY
PREGNANT / ABORTION / POST-PARTUM / POST-MENOPAUSE / THCUL / THROAT / URTHC / URETHRAL / 9391 / CHLAMYDIA DNA
HISTORY / EACUL / EAR / VACUL / VAGINAL / 9390 / GONORRHEA DNA
EYCUL / EYE / WOCUL / WOULND / 9391 / OCCULT BLOOD
PREV. ABNORMAL CYTOL FINDINGS / GOCUL / GC / ROCUL / CULTURE (ROUTINE) / 0293 / OVA & PARASITE
CONTRACEPTIVES / DATE / SPCUL / SPUTUM / URCUL / URINE / WTM / WET MOUNT
HYSTERECTOMY / HORMONES / IUD / STCUL / STOOL / GSP / GRAM STAIN
COPHORECTOMY / TOTAL / SUPRA CX / SOURCE / OTHER
RADIATION RX / DATE / DIAGNOSIS OR COMMENTS
OTHER / HORMONES RX / CHEMO RX
LMP / DATE COLLECTED
SOURCE / CERVIX / ENDOCERVIX / VAGINA
CYTOBRUSH / OTHER SITE
LAB USE ONLY (DO NOT WRITE BELOW THIS SPACE)
DATE RECEIVED / DATE REPORTED
STATEMENT OF SPECIMEN ADEQUACY / INSURANCE BILLING INFORMATION
GENERAL CATEGORIZATION / PRIMARY INSURED / INSURANCE COMPANY
DESCRIPTIVE DIAGNOSIS / ADDRESS
HORMONAL EVALUATION / POLICY NO. & I.D. NO. / ICD9 CODE
ADDITIONAL COMMENT / LEGEND
CYTOTECHNOLOGIST / PATHOLOGIST / SS / Serum Separator / GY / Grey / B / Blue / U / Urine
R / Red / L / Lavender / RB / Royal Blue / G / Green