Directions for completing lab request form

Directions for completing the laboratory test request form are listed below. Please follow these steps to ensure that all necessary information is provided for accurate testing, reporting, and billing. All pertinent information should be legibly PRINTED.

1. Attach the patient's registration label (if available), which corresponds to the specific episode/date of patient care.

2. Print patient's name (Last, First, MI), sex, history number, and date of birth. (This does not need to be completed if a UVA Patient Registration Label has been affixed to the form.)

3. Print the ATTENDING physician's name (Last, First) and provide the physician's phone/PIC #. The physician signature is required only if the specific test request has NOT been documented in the patient's medical chart.

4. Provide the specific clinic name or service location code. (This does not need to be provided if a UVA Patient Registration Label has been affixed to the form.)

5. Indicate collection date and time of specimen.

6. Check appropriate plan for billing purposes. FOR INSURANCE BILLING and direct PATIENT BILLING: if the patient has been registered into a UVA system and the insurance information has been reviewed and updated by the physician/clinical service for the specific episode of care, the blue shaded area on the form is not required to be completed. If the patient has not been registered into a UVA system by the physician/clinical service, the information in the blue shaded area must be completed. FOR ACCOUNT BILLING TO A PHYSICIAN OR INSTITUTION: the account number (W# or G#) must be provided. The blue shaded area does not need to be completed.

7. Mark the requested test procedure(s) with an X in the appropriate box to the left of each test requested. If the desired test does not appear on the form, PRINT the full test name in the space provided for Other Routine Tests.

8. Provide an ICD-9 code (diagnosis, chief compliant/symptom) for EACH test ordered which documents the medical necessity for each test ordered. ICD-9 codes are MANDATORY.

9. Mark the requested STAT procedure(s) with an X.

10. On the back of the top copy of the test request form is information that is provided for medical necessity requirements when ordering tests on Medicare patients. When appropriate and indicated, the physician should review this information with each Medicare patient and check the indication that applies. The patient should be instructed to signature the Advance Beneficiary Notice, if there is an indication that Medicare may deny payment of the laboratory services requested.



PLACE TOP COPY OF THE COMPLETED TEST REQUEST FORM IN THE SEPARATE OUTER POCKET OF THE PLASTIC TRANSPORT BAG TO PREVENT POSSIBLE CONTAMINATION.  THE pink COPY MAY BE RETAINED FOR THE PHYSICIAN RECORD.