Laboratory Requisition
The following are the directions on how to fill out the Laboratory Alliance test requisition:
1 Specimen Information
§ Include Date and Time Collected and initials of the person who collected the specimen.
§ COPY TO: - Indicate full physician name (ie: Dr. Joe Smith) if an additional copy needs to be sent to another physician.
§ Physician signature is REQUIRED in this section for Medicaid patients only.
2 Patient Information
§ Fill in patient’s Name and Date of Birth (DOB)
§ All other information should be filled in completely or attach a billing face sheet to the requisition.
3 Insurance Billing Information
§ Fill in completely or attach a billing face sheet to the requisition.
4 ICD9/Dx Code
§ Fill in theboxes with the appropriate ordered test Diagnosis codes.
5 Patient Authorization
§ Make sure that the patient signs the authorization.
6 Test Orders
§ Please indicate with a √ to the left of the test name what test(s) the physician has ordered.
7 Advance Beneficiary Notice (ABN)
For NCD information: http://www.cms.hhs.gov/mcd/index_section.asp?ncd_sections=40
§ Please fill in the patient’s name and Medicare #.
§ In the section “Listed or Checked Items Only,” please indicate with a √ 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 it may be a test for experimental or research only. 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.
§ Under “Estimated Cost: “ – you must provide the patient with an estimated cost of the test(s).
§ Under Options, please have the patient select an option.
§ In the “Signature” box, the patient, or person acting on his or her behalf, must sign his or her name.
§ 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.
§ Under “Addition Information:” any additional clarification for the beneficiary may be entered.
Important Note: All of the sections of the ABN need to be filled in, otherwise the ABN will not be acceptable by Medicare.
